Touchstone EnergyÒ Camp Application Form Camp Tecumseh YMCA Outdoor Center - Brookston, IN June 4-7, 2008      Indiana’s Rural Electric Cooperatives      Sponsoring Cooperative:

                                     

                                                           

                          
                            

                       

6^TH GRADE STUDENTS ARE ELIGIBLE TO

APPLY.   __6  _ STUDENTS WILL BE SELECTED

TO ATTEND THIS UNIQUE CAMP AT NO COST!   
 

Please print neatly or type.  Applicants must be in the 6^th grade this year to attend camp in the summer.
Applications must be submitted to Southeastern Indiana REMC by March 7, 2008

                                   

Student’s Name:  ___________________________________________  Grade: _______ Age: _____

Nickname
(as you would like it to appear on a name badge):________________ Shirt Size (Adult):__________

Address:  ______________________________________City: ________________ Zip: ___________

 

Parent/Guardian’s Name (s):  __________________________________________________________

 

Telephone:  (___)______-______  Date of Birth: __________  Email address:____________________ 

 

Name and address of Middle School :  ___________________________________________________

_________________________________________________________________________________

Does your household receive electricity from an REMC or REC?   Yes __________   No _________

 

If yes, give the name of cooperative: ___________________________________________________

 

Any dietary restrictions that need to be addressed during the trip?  Please explain.

_________________________________________________________________________________

_________________________________________________________________________________

 

_________________________________________________________________________________

 

Photos and/or videos will be taken of the participants and their entire group throughout camp activities.  We will use the
images for future promotional materials or as public information in your local newspaper. If you DO NOT want your
child to appear in these images, please submit your wishes in writing to your local cooperative, along with your
application.  Thank you.