Registration Form – Youth Nations Leadership Movement

Youth Nations Camper Registration Form

Camper Information
Name *

First

Last
Email Address *
Mobile Number *
Age: *

10 - 12yrs 13 - 15 yrs 16 - 18 yrs 19 -21yrs
Date of birth *
Gender *

Male Female
T-shirt Size

Small Medium Large X Large
Swimming Skill

Strong Swim Well Weak Need Help
Hight *
Weight *
Name of School Camper Attends *
Current Grade *
Upload Photo of Camper *
Select Image
Image must be less than 1mb
Parent/Guardian Contact Details
Parent/Guardian Name

First

Last
Parent/Guardian Email Address *
Parent/Guardian Mobile Number *
Parent/Guardian Home Number *
Parent/Guardian Work Number *
Medical Information

This section is required in the event of a medical emergency. If no response is given, we will assume the camper can engage in ALL camp-related activities.
Does the camper have any physical conditions that limit or prohibit activities? Please specify:
Does the camper have any allergies or prior medical conditions? Please list ALL
Do you have any Medical Aid?

Yes No
Name of Medical Scheme
Name of Primary/Main Member
Medical Scheme Membership Number
ID Number of Primary/Main Member
Upload Photo of Medical Aid Card
Select Image
Please list any additional information you deem necessary
Additional Emergency Contact
Additional Emergency Contact Name

First

Last
Additional Emergency Contact Number *
*

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