Trip Reservation Form

 

Ballard’s Resort Fishing Trip

Sunday, June 30th – Wednesday, July 3, 2019

 

 

 

Name (1)           __________________________________            Nickname:            ________________________________

 

Address:            _____________________________________________________________________________________

 

Email:              _____________________________________________________________________________________

 

Home Phone:   __________________________________            Cell Phone: ___________________________________

 

Date of Birth:            _____________________________________________________________________________________

 

Emergency Contact Name: __________________________________     Cell Phone: _____________________________

 

Roommate’s Name: _________________________________________________________________________________

 

 

Special Requests (dietary, accommodations, wheelchair etc…) ____________________________________________

 

__________________________________________________________________________________________________

 

Celebration During the tour: ____________________________________________________________

 

Fishing License:           Have one:  ____________          Purchase one from Ballard’s ($37) _____________

 

Payment Information

$200 Deposit and form due by:  March 31, 2019

$815.00 Final Payment due by:  June 14, 2019

 

 

Please mail this form along with your payment to:             FSB Connect Club - Kathy Leesekamp

1240 8th Ave

Marion IA 52302

 

 

Signature:        ____________________________           Signature:        ______________________________

 

Date:                ____________________________           Date:                ______________________________

 

 

 

 

Kathy Leesekamp-Connect Club Director (319) 294-2900