Backpack Trip 2024 Application
July 12 - 14, 2024, TBD
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Parent Email
*
example@example.com
Phone Number
Mobile Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Medical Information
Does the child have allergies including asthma?
*
Please explain on the field provided
Is the child currently under medication?
*
Please provide the details, the name of the medication and period of intake
Back
Next
Contact Information in Case of Emergency
Name
*
First Name
Last Name
Contact Number
*
-
Area Code
Phone Number
Relation to Child
*
Name
First Name
Last Name
Contact Number
-
Area Code
Phone Number
Relation to Child
Back
Next
Signature of applicant or guardian representative
*
Back
Next
YFC Consent and Release of Liability
Signature
*
Date
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Back
Next
Back Pack Trip Fee
prev
next
( X )
Fee
$
125.00
Quantity
1
2
3
4
5
6
7
8
9
10
Total
$
0.00
Credit Card
Submit
Should be Empty: