NJ/DE District Youth

North American Youth Congress Application

Name: _______________________________________
Street Address: _______________________________
City/State/Zip: _______________________________

Local Church: ________________________________

Pastor's Name: _______________________________
Pastor's Signature: __________________________________________________

TWO EMERGENCY CONTACT PEOPLE (Must be indicated or application will be reject

Name: ______________________________________
Daytime/Evening Phone: ___________________________________________________________________
Name: ______________________________________
Daytime/Evening Phone: ___________________________________________________________________

Permission Slip & Medical Emergency Release

____________________________________________
(Applicant's Name)

I give my permission for emergency medical attention.

Some physicians and hospitals will not treat minors without a signed statement of permission from
the parent or guardian. Your signature is mandatory for your child's participation on this trip. In an
emergency, you will be called.

Please list any physical conditions your child has that may demand attention or medications they are
required to take: __________________________________________________________________________
___________________________________________________________________________________________

We will do our best to group attendees with desired roommates; however, we must have four to a
room to offer the trip at this price. If you or your youth group are not able to meet this requirement,
and you are opposed to us placing additional people in the room to reach the required number, an
additional premium per person will apply (please call Danny Hamm @302-893-2482 for pricing).

Please list the names of desired roommates.

1) _Me______________________________________
2) __________________________________________

I am a/an (check one): __ Chaperone __Attendee

E District Youth
Youth Congress Application
Email Address: _______________________________
Phone Number: ______________________________
Date of Birth: ________________________________

How long have you attended your church? _______

Pastor's Phone Number: _________________________
______________________

E (Must be indicated or application will be rejected)

Relation: ____________________________________
_____________________________________________
Relation: ____________________________________
_____________________________________________

p & Medical Emergency Release

has my permission to attend the North American

Youth Congress held in Columbus, OH and
sponsored by the NJ/DE Youth Department.

nors without a signed statement of permission from

atory for your child's participation on this trip. In an

____________________________________________
(Parent/Legal Guardian's Signature)

s that may demand attention or medications they are

____________________________________________
____________________________________________

sired roommates; however, we must have four to a

ur youth group are not able to meet this requirement,
eople in the room to reach the required number, an
e call Danny Hamm @302-893-2482 for pricing).

3) __________________________________________
4) __________________________________________