Copy the form below, fill it out and email it to youthforlibertycamp@gmail.com
OR
Print out the form below, fill it out and mail it to Jamie Durfee
11892 N. HWY 34
Preston, ID 83263
Payment is due at the time of registration, with $100 held as a non-refundable deposit. Please send a check made out to Youth for Liberty Camp with the registration form or use the Paypal feature on our website.
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Cost: $225 before May
1st, 2013
$250 after May 1st
$10 off for each additional child in
family after May 1st
Includes lodging, materials and all meals from
Monday dinner through Thursday dinner.
Includes lodging, materials and all meals from
Monday dinner through Thursday dinner.
Final registration due July 1st, 2013
___________________________________________________________________________________
Youth for Liberty Camp
August 5-8, 2013
Name _______________________________________ Birthdate ____________________________
Address
________________________________________________________________________
Participants’ parent or guardian _________________________________________________________
Home telephone number _________________________Work
_________________________
Cell phone number(s)
___________________________ ____________________________T-shirt size ________
Medical information:
Does the participant have any of the following:
________
Special diet ________Allergies
________Medication ________Chronic/recurring
illness
________Surgery
or serious illness in the past year ________Physical
conditions that limit activity
If yes, explain below.
Use back if more space is needed.
Insurance information:
Insurance company:
______________________________________________________________
Group number _______________________________ Policy
number _________________________
Address: ______________________________________________________________________
Telephone number:
_______________________________________________________________
I give consent for YFL to use pictures of camp, which may include my child, for publicity purposes. I give permission for my child to participate in the Youth For Liberty Camp and authorize the agents and administrators of the camp to administer emergency treatment to the above-named participants for any accident or illness and to act in my stead in approving necessary medical care. This authorization shall cover the travel to and from the activity, if applicable. I will not hold Youth for Liberty Camp or its agents responsible for accident, injury, or illness.
Parent or guardian signature
__________________________________
Date _____________________
Date _____________________