New Life Northwest Youth Registration

Youth Name

First NameLast Name

Birth Date

Date

Grade Going Into

Shirt Size

Sex

Parent Name

First NameLast Name

Email

example@example.com

Relationship To Youth

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance Provider

Policy Number

Name of Church You're Attending With

Name A Few Friends You Would Like To Be In A Cabin With

Does Your Youth Have Any Behavioral Or Relational Issues We Should Know About? If Yes, Please Explain.

Is The Above Youth Currently Taking Any Medication? If Yes, Please List All Medication(s).

Does The Above Youth Have Any Allergies To Medication If Yes, Please List All Allergies.

Does Your Youth Have Any Other Allergies Or Sensitivities? If Yes, Please List All Allergies or Sensitivities.

Does Your Youth Have Any Medication(s) That Need To Be Administered By A Nurse?

IF YOUR YOUTH HAS MEDICATION THAT NEEDS TO BE ADMINISTERED BY A NURSE PLEASE CONTACT LYNNETTE CAMP AT NLNWFamilyCamp@gmail.com TO ARRANGE

Do You Consent To Your Youth Receiving Over The Counter Medication (i.e., Tylenol, Advil, Tums, Benadryl, etc?)

We Will Have GLUTEN FREE AND DAIRY FREE Meal Options Available At Each Meal, Please Select If Your Youth Will Need One Or Both Of These Options

Medical Consent:
I, the undersigned, a parent or legal guardian of First Name* Last Name* a minor, do hereby authorize any member of the NLNW staff as an agent for the undersigned to consent to any X-ray, examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the Medicine Practice Act.
It is understood that this authorization is given in advance of any specific diagnosis,
treatment, or hospital care being required but is given to provide authority and power on the part of the aforesaid agent to give specific consent to any and all such diagnosis, treatment, or hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable. Every effort will be made by the staff to notify the parent or legal guardian before any action is taken. This authorization shall be in effect from August 2-7, 2026.

Signature of Parent or Legal Guardian:
Signature* First Name* Last Name*

Liability Release and Consent
As Parent/Guardian, I have voluntarily applied, on behalf of my child, to participate in this church-sponsored program. I understand that there are risks in my child’s/ward’s presence, transportation, and participation in this church-sponsored program. I hereby agree on behalf of my child to assume any and all risk of bodily injury, death, or property damage, arising out of, or caused by my child’s/ward’s presence and participation in the church -sponsored program. I hereby release the church and any of its affiliated organizations, agents, or employees, from all actions or claims that my
child, my child's heirs and/or legal representatives now have or may hereafter have for bodily injury, death, and property damage resulting from my child’s participation in this church sponsored program. I have carefully read this agreement and am aware that this is a release of liability and contract between myself and NLNW Family Camp and by submitting this form, I am signing it of my own free will.

Signature of Parent or Legal Guardian:
Signature* First Name* Last Name*