	Improving Life, One Breath at a Time®
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2007 Camp Registration Form

Registration deadline July 15, 2007!

Camper Name:
Age:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Parent/Guardian Name:
Daytime Phone:
Evening Phone:
Alternate Phone:
Email Address:
Closest Hospital (Choose from list below)
	*United Hospital Center
	*Ohio Valley Medical Center
	*Camden Clark Memorial Hospital
	*Cabell Huntington Hospital
	*Jefferson Memorial Hospital

How did you hear about Camp Catch Your Breath?

You will be sent a registration packet in the mail. If you have any questions please contact Chantal Centofanti-Fields at 304-342-6600.