Please be sure you/your student has a
Youth Liability Form
on-file for 2026-2027 prior to participating in the Youth Camping Trip.
Student Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name
*
First Name
Last Name
Parent Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent Email
*
example@example.com
Student Birthdate
-
Month
-
Day
Year
Date
Are you under care of a physician at this time?
*
Yes
No
Please describe:
Are you currently taking prescribed medication?
*
Yes
No
Please describe:
Please list any special needs or physical disabilities we should be aware of *including food and other allergies*:
*
Enter N/A if none.
Payment Information
Name of person submitting payment (if different than student name):
First Name
Last Name
Email for contact regarding payment:
*
example@example.com
Phone Number for contact regarding payment:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please select the option(s) that apply to you:
*
I am paying in full via this form.
I have talked to Nathan about using Youth Activity Funds I helped raise to cover the cost of this activity. (Enter any remaining balance as payment below.)
I will pay by cash or check. (Options: submit payment via giving envelope in a giving box on the Life Church campus, or mail payment to Life Church - PO Box 5596, Salem, OR 97304)
Camping trip total cost: $100
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