Leadership Camp (PA) – Camper Registration | Youth Service International

Name*

First Last

Date of Birth*

Home Phone Number*

e.g. 123-456-7890

Mother's Name

Mother's Cell Number

e.g. 123-456-7890

Mother's Email

Father's Name

Father's Cell Number

e.g. 123-456-7890

Father's Email

Preferred Parent Contact*

Mother
Father

Please select one

Preferred Parent Contact Medium*

Phone call
Text
Email

Please select one

Street Address*

City*

State*

Zip*

Education

School*

Grade (entering next fall)*

Grade Point Average*

Extracurricular Activities*

Medical & Photo

Insurance Company*

Group Number*

Policy Number*

Insurance Company Phone Number*

Health Information*

Any pertinent health information, allergies, medications, etc.

Electronic Signature for Medical & Photo/Video Release*

I, the parent or guardian of the above-named applicant, hereby delegate authority to the Directors of the Leadership Camp to arrange whatever medical treatment they deem necessary for the above-named applicant during his stay at the camp. Also, I hereby authorize and consent to the use and reproduction by YSI staff or an authorized agent or assignee of any and all photographs/video taken of the above-named applicant for the purpose of promoting YSI programs, without any compensation to me. All film (and digital media), 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.

Miscellaneous

Shirt Size*

These are youth sizes.

Any special diet requirements?*

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

Yes
No

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 starting about a month before the camp.

Have you had a son attend the Leadership Camp before?*

Yes
No

A brief phone interview is required for any family who has not had a son attend the Leadership Camp before. A staff member will call you within two weeks of your submitting the registration form.

Payment Status*

I will pay online
Check has been sent in mail
Other (please contact us)

Reference*

Who recommended this program to you?

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