Registration Form

Shelby District
Merit Badge Day, January 29, 2005

Registration Form
"Early Bird deadline January 21, 2005"
(Please type your responses in the spaces provided before printing the form.)

First Name: Last Name:

Address:

City: State: Zip:

Day Phone: () Night Phone: ()

Troop: District: Council:

Scoutmaster:

Scoutmaster's Phone: ()

Scoutmaster's Email:

Please list your 1st and 2nd choices per session.

Session:
Merit Badge:

Morning:

Afternoon:

Comments?

Cost: $10.00 if registered by Jan 21, 2005 or $15.00 after Jan 21. NOTE: Scouts not registered prior to Jan 21 are not guaranteed the Merit Badge class they registered for and may be assigned to other classes. Fill out this form entirely and mail it with payment to the:

Birmingham Scout Shop
516 Liberty Parkway
Birmingham, AL 35242

Or, you may charge to your credit card:

CHECK#___ VISA __ MC __ Account # ____________________ Name _________________ EXP Date _____________

Shelby District Merit Badge Day Account Number: 1-6801-255-20

First Name:	Last Name:
Address:
City:	State: Zip:
Day Phone: () Night Phone: ()
Troop: District: Council:
Scoutmaster:
Scoutmaster's Phone: ()
Scoutmaster's Email:

Please list your 1st and 2nd choices per session.
Session:	Merit Badge:
Morning:
Afternoon:
Comments?