2019 LICYPAA Campout Registration Form
Please fill out this form completely.

Suggested Contribution: $30

Can be paid via: Cash or check made out to LICYPAA & given to a trusted servant of LICYPAA, checks can also be mailed to P.O. Box 975 77 Ireland Place Amityville, NY 11701 or Venmo LICYPAA Treasurer @LICYPAA.

Name *
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Phone
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Email
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Homegroup *
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Do you wish to be contacted about upcoming events? *
Sobriety Date *
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Emergency Contact Name & Number *
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Dietary Restrictions *
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