2022 Alexandria YIP Registration | Youth Impact Program

YOUTH INFORMATION

Name of Youth Participant

Email

State

Date of Birth

Grade as of Fall 2022 (6th, 7th, 8th Grade)

School

School District

Height

Weight (in lbs)

Does your child have any medical/physical conditions?

Is your child currently on medication?

Does your child have any allergies?

T-Shirt Size

Shorts Size

Parent Guardian Information

Name of Parent or Guardian

Relationship to student

Cell Phone Number(Required)

Email(Required)

Emergency Contact information

Name

Relationship to Student

Cell Phone Number

Statement of Responsibility:

I, the Legal Guardian, understand that in completing this application, I support my child in participating in this academic and athletic program

I will not schedule vacation time or admit my child into other camps during the program dates, otherwise I forfeit their spot as to allow another camper to attend

I assume FULL risk and responsibility for their commitment and participation in this program and I agree to waive any claims against the YIP and the Host Organization

Entering Parent/Guardian name here authorizes legal representation for youth participation

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