NYC Registration Form for Chaperones & Youth
Youth (ages 13-18) must be accompanied by a chaperone (aged 21+)
Chaperone Details:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
example@example.com
Alberta Health Care Number:
*
Gender
*
Male
Female
Birthdate
*
-
Month
-
Day
Year
Youth Details:
Youth Information
Required Waivers
Waiver
*
As a participant of the Native Youth Conference (NYC), I accept full responsibility for any risks, liabilities or injuries that may occur to myself. Native Youth Conference and its organizers cannot be held accountable.Native Youth Conference is not responsible for anyone who leaves the conference voluntarily and without permission from the Native Youth Conference.
Picture Release
*
By registering for Native Youth Conference, I give Native Youth Conference, InterAct Ministries and Intertribal Life Ministries permission to use photos taken in their publications and/or website and/or videos. I understand that my name, in some cases, may be used in the pictures and I will not be compensated for such photo use. I give my full permission for such photos to be used, both now, and in the future.
Pay for Youth & Chaperones
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# of Chaperones & Youth Registering - Pay with Credit Card
How many youth, plus chaperone, are you submitting payment for?
$
160.00
CAD
Quantity
1
2
3
4
5
6
7
8
9
10
# of Chaperones & Youth Registering - Pay with Cash/Cheque at Door
$
Free
CAD
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card
Please verify that you are human
*
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Submit Registration
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