2023 Alexandria YIP Registration

YOUTH INFORMATION

Name of Youth Participant(Required)

Nickname of Youth Participant

Gender

Male

Female

Email(Required)

Address(Required)

Street Address City ZIP Code

State(Required)

Date of Birth (Required)

Grade as of Fall 2023 (6th, 7th, 8th Grade)(Required)

School(Required)

School District(Required)

Height

Weight (in lbs)

Does your child have any medical/physical conditions?(Required)

Is your child currently on medication?(Required)

Does your child have any allergies?(Required)

Please list all medical conditions, allergies and medications(Required)

If none, put none

T-Shirt Size

Shorts Size

Parent Guardian Information

Name of Parent or Guardian(Required)

Relationship to student(Required)

Cell Phone Number(Required)

Email(Required)

Emergency Contact information

Name(Required)

Relationship to Student(Required)

Cell Phone Number(Required)

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(Required)

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(Required)

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(Required)

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

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