Youth Camp Registration Form

NLI Youth Camp Registration 2021
Camper Information
Campers Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Age during camp*
Gender*

MaleFemale
Grade Completed in spring of 2021*
Parent/Guardian Information
E-mail*
Father*

First NameLast Name
Mother*

First NameLast Name
Home Number*

Area CodePhone Number
Mom Cell Number

Area CodePhone Number
Dad Cell Number

Area CodePhone Number
Please select week of camp. Pay the $75.00 deposit to reserve your campers week of camp. Your balance can be paid after you receive your confirmation email. To receive the family discount please register siblings on the same day. The deposit is nonrefundable.*
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Teen Week, 13-17 years, 7/4-7/9$75.00

Junior High 1, 11-13 years, 7/11-7/16$75.00

Junior 1, 8-10 years, 7/18-7/23$75.00

Junior High 2, 11-13 years, 7/25-7/30$75.00

Junior 2, 8-10 years, 8/1-8/6$75.00

Junior Mini Week, 8-10 years , 8/4-8/6$75.00

Adventure 1, 14-18 years, 7/18-7/23$75.00

Adventure 2, 14-18 years, 8/1-8/6$75.00

Store Card$25.00

Store Card$35.00

Store Card$50.00

Total $0.00
Cabinmate Choice 1
Optional
Cabinmate Choice 2
Optional
Church You Attend
Church Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
T Shirt Size
All Campers Receive a Camp T-Shirt
Camper Medical Form
Medications Taken Regularly
Special Conditions
Allergies
Recent Exposure to Contagious Disease
Date of Last Tetanus Shot*
Insurance Information*
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
I authorize the following individuals to pick up my child from camp.*
As parent or guardian; in case of medical emergency I hereby authorize New Life Island camp staff to obtain emergency medical treatment for the child named on this form. I certify that my child is in good health and is able to participate in the camp program. I hereby give permission for my child to attend camp and to participate in all camp activities including high and low ropes, swimming, and canoeing and tubing done in conjunction with Bucks County River Country. I also give permission for my child's picture and/or digital image to be used for camp promotional purposes. This is your electronic signature, just like the signature on a paper form.*
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NLI Youth Camp Registration 2021