Campout Refund Request

• Refund requests must be received within 30 days of the campout.
• An administrative fee of $2.00 per member will be charged for each refund.
• Refunds must be approved by the Nation Navigator.
• Members may be required to produce a receipt or other evidence of payment.
• Yomechas Federation reserves the right to refuse any refund request.

Payee Information

Name: Phone:

Street Address:

Town: State: Zip:

Campout Information

CAMPOUT: Fall     Winter    Spring Campout Date:

NATION: Heartland Meadows Pioneer Prairie   Plains Streams TBTM Woodland

Your Circle's Name:

Amount and Approvals

Date of request: Amount $

Non-attending Member(s)

Reason:

Signature of Adult Member:

Signature of Nation Navigator:

Treasurer Use Only

Check # Date: Amount $ Acct #

Revised 6/03