Leadership Camp (Indiana) – Camper Application

Personal Information

Name*

First Last

Mother's Name*

Father's Name*

Address*

Street Address City State ZIP Code

Home Phone Number*

e.g. 123-456-7890

Emergency Phone Number of Parent*

e.g. 123-456-7890

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
No

Any special diet requirements?*

Any special medical issues?*

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

We would like to help parents coordinate transportation to/from the camp with other parents in their area. To do this, we find the best approach is to share the mailing address and home phone number of registered families with each other. Your contact information will not be given to any third parties. Please mark whether you would like your contact info to be shared and whether you would like to receive that of others. If you mark yes, we will send you this contact information as the camp approaches.

Yes
No

Have you attended the Leadership Camp before?*

Yes
No

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.

Reference*

Who recommended this program to you?

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