Name:___________________________________________ ID # ___ ___ ___ ____

Address:____________________________________________________________

              ____________________________________________________________

Phone (_______) - ________ - ____________________

Email:______________________________________________        (  ) Adult    (  ) Youth

Fee: $28.00

Mail completed forms, Medicals, and fee
                                             to:  Kittatinny Lodge 5
                                                   Hawk Mountain Council, BSA
                                                   5027  Pottsville Pike
                                                   Reading PA  19605

Also a Class 1 medical form must be filled out and sent in with registration