NCYC 2023

**Complete this form as well as the Hold Harmless Agreement and $150 Downpayment by March 20, 2023

 

Personal Information
Name
  •  
Date of Birth //
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Student Cell Phone Number --
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Student E-mail Address
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Name of Parent(s)/Legal Guardian(s)
  •  
Address of Parent(s)/Legal Guardian(s)
  •  
Parent Phone Number --
  •  
Parent/Guardian E-mail Address
  •  
Tshirt Size
  •  
Days I'm Available
  •  
 Please check any days you are unable to attend. If unsure, leave blank.
Medical Information
Family Physician
  •  
Phone Number of Physician --
  •  
Allergies
  •  
Current Medications
  •  
Medical History
  •  
In Case of Emergency, Please Contact:
Name
  •  
Phone --
  •  
Name 2
  •  
Phone 2 --
  •  
  •  
 
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