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AGVM Registration Form
1. REGISTRACIJA Registration
Àþuolo-Gintaro Lavinimo Mokykla Àþuolo-Gintaro Leadership Camp
Ðestadiená Rugsëjo 1-8, 2009, 12:00 v.p.p. Saturday August 1-8, 2009, 12:00pm
Kanados Rajono Romuva Stovyklavietë Camp Romuva, Canada
STOVYKAUTOJO/JOS PAVARDË Camper Surname VARDAS Name
TËVØ/GLOBËJO: PAVARDË Parent/Guardian Surname VARDAS Name
ADRESAS Address MIESTAS City VALSTYBË Country ZIP/POSTAL CODE
TËVØ/GLOBËJO: ADRESAS Parent/Guardian Address MIESTAS City VALSTYBË Country ZIP/POSTAL CODE
( ) ( )
STOVYKAUTOJO/JOS TELEFONO NUMERIS Camper Phone Number CEL NUMERIS Cell Number GIMTADIENIS Birth Date (dd/mm/yy)
( ) ( )
TËVØ/GLOBËJO TELEFONO NUMERIS Camper Phone Number CEL NUMERIS Cell Number
STOVYKLAUTOJO/JOS E-PAÐTO ADRESAS Camper E-mail Address TËVØ/GLOBËJO E-PAÐTO ADRESAS Parent/Guardian E-mail Address
paskiltininkas/kë skiltininkas/kë vyrs. skiltininkas/kë
STOVYKAUTOJO/JOS VYRESNIÐKUMO LAIPSNIS: Camper Scout Rank:
taip ne
ESU SUMOKËJÆS/USI LSS NARIO MOKESTÁ: I have paid my Lithuanian scouting membership fee: Yes No
TUNTAS/VIETININKIJA Council/Area PAREIGOS Duties
( ) ( )
TUNTINIKO VARDAS IR PAVARDË Council Leader’s Name & Surname TEL. NR. Phone Number CEL NUMERIS Cell Number
ADRESAS Address MIESTAS City VALSTYBË Country ZIP/POSTAL CODE
STOVYKLOS MOKESTIS: Camp Fee
-- Kanadoje Gyvenantiems:
J.A.V. Gyvenantiems: $325 US $400 CDN
U.S. Citizens: Canadian Citizens:
Èekius raðyti Lithuanian Scouts Association (G.A.M.) Please make cheques payable to: Lithuanian Scouts Association (G.A.M.)
Mokestis ir registracija pageidaujama atlikti iki liepos 1d. 2009. Registration and payment due July 1, 2009.
REGISTRACIJOS MOKESTÁ SIÛSTI: Please submit registration with payment to:
PRIE ÐIOS REGISTRACIJOS
J.A.V. GYVENANTIEMS: U.S. Citizens KANADOJE GYVENANTIEMS: Canadian Citizens
PRISEGTI SEKANÈIUS DOKUMENTUS:
v.s.fil. Romas Rupinskas s.fil. Algis Simonavièius
The following documents are included with my registration:
370 56th Street 40 Wilgar Road
Romuva Indemnification
Claredon Hills, Illinois Etobicoke, Ontario
Physical Fitness Certificate
U.S.A. 60514 Canada M8X 1J5
Kursanto Skautiðkas Patirtis Campers scouting experience
E-MAIL: rrupinskas@aol.com E-MAIL: simona@ica.net
TEL: 603-887-0189 Signed, ‘Code of Conduct’
TEL:416-239-7226
Signed, AGVLM Taisyklës / Rules
