Leadership Camp (PA) – Camper Registration

"*" indicates required fields

Name*

First Last

Mother's Name*

Father's Name*

Address*

Street Address City State ZIP Code

Home Phone Number*

Emergency Phone Number of Parent*

Email Address - Parent*

We will confirm your application using this email.

Date of Birth*

Education

School*

Grade (entering next fall)*

Grade Point Average*

Extracurricular Activities*

Miscellaneous

Shirt Size*

Does your son know how to swim?*

Yes

Any special diet requirements?*

Any special medical issues?*

Would you like to share your contact info with other parents in order to coordinate transportation?*

Parents should make transportation plans for their son to go to and from the Leadership Camp. In order to facilitate these plans, we help to connect parents who are interested in carpooling with other parents in their area.

Mark 'yes' on this question if you would like your contact info (city, state, home phone number) to be shared and whether you would like to receive that of others. For those who mark 'yes,' we will send you this contact information as the camp approaches.

Yes

Have your son attended Leadership Camp before?*

Yes

Electronic Signature for Photo Release*

I hereby authorize and consent to the use and reproduction by YSI staff or an authorized agent or assignee of any and all photographs taken of the above-named registrant for the purpose of promoting YSI programs, without any compensation to me. All images and videos, together with any prints, shall constitute property of YSI, solely and completely. Enter your name above to confirm both the medical and photo release, and your registration will be complete. If you type "no", then we will have to discuss other circumstances that can be agreed to for your son to attend the camp and the registration will not be complete until we can reach an agreement.

Reference*

Who recommended this program to you?

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