Youth Resiliency Camp CAPT/WYLD Youth Camp Step 1 of 5 20% Youth InformationName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemaleOtherAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code What school is this youth currently attending? Parent InformationName(Required) First Last Phone(Required)Email(Required) Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code **Required if differs from youth Special AccommodationsDietary Restrictions Please List Above.Does your child require any special accommodations?Please List Above. Emergency Contact InformationPlease list THREE emergency contact information for your child. Also indicate the adults who are allowed to pick up your child.Emergency Contacts/Adults who can pick up your youth(Required) Would you like to cover the cost of your childs registration?This camp is FREE to all youth. Covering the cost of your child registration would allow us to expand the reach of this Youth Resiliency Camp. All funds would go back into the Child Abuse Prevention Team Fund.Ticket Type(Required) Yes Not right now T-shirt size? Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult X-Large Adult XX-Large Total Payment MethodPayPal CheckoutCredit Card MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name CAPTCHA
