Youth Registration 2012

Please complete the following information and submit.  Medical Information & Release form  is also required.   Please print, complete and mail to LVCM PO Box 601 Elizabethville Pa 17023 or present to Youth leader or committee representative at campmeeting.  

2012 Youth Information
Name *

First
Last
Home Phone *

### 		-
### 		-
####
Cell Phone

### 		-
### 		-
####
Address *

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Age *
Birthdate *
Grade *
School
Church attending
Likes
Dislikes
Strengths / gifts you possess
Areas you need help.
List your 3 favorite games (any kind)
Other Information

Paren/Guardian Information

Mother/Guardian

First
Last
Phone Number

### 		-
### 		-
####
Address (if same as youth, leave blank)

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Email
Father/Guardian

First
Last
Phone Number

### 		-
### 		-
####
Address (if same as youth, leave blank).

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Email
Additional information

Please note: Medical information & Release forms (located on a separate page of the website) should be printed, completed & mailed to PO Box 601 Elizabethville PA 17023 or given to Youth Leader or committee member at camp. It is extremely important that this information be on file for every youth. Your cooperation is greatly appreciated.

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