Name________________________________________________________________________

Address______________________________________________________________________

City______________________________________State____________Zip_________________

Daytime Phone_________________________E-mail___________________________________

I want to make 2004 a better year for our youth.   List me as a Waterman Summer Campership sponsor.

______  4 campers at $85 each 		$340

______  3 campers at $85 each 		$255

______  2 campers at $85 each 		$170

______  1 camper at $85 each		$ 85

______  Other (all donations are welcomed)	$_____

______  I have enclosed a check in the amount of $_______made payable to:  

	Waterman Center Camperships.

______  Please bill by credit card (MasterCard / Visa) for the amount of $____________________

My credit card number is____________________________________expiration date__________

Signature_____________________________________________________________________

______  I am unable to send a contribution at this time, but I pledge to send in $________________