Nylt Individual Registration Form


Iroquois Trail Council National Youth Leader Training (NYLT) Individual Registration Form 2016
Scout’s last name
The Official BSA Health and Medical Form must accompany this form with all sections completed (including Signature of physician).
Personal Information:
Scouts name: ___________________________________________Age as of 7/31/2016 ________ Male or Female: ____________ Rank _________________
Mailing address: _____________________________________________________________________ Phone #: (______) ____________________________
City/State/Zip _____________________________________________________________________
Shirt Size: Adult
(Please circle size)
E-Mail __________________________________________ Unit Leadership Position _____________
2- Shirts 1-Hat provided
# of extra shirt_________
Approximant cost Shirt $8.00 Hat $ 10.00 # Of extra hat____________
Leaders Certification:
I hereby certify that this applicant will be at least 13 years old and a First Class Scout or registered Crew member by the first day of the NYLT Conference
week. The applicant holds or plans to soon hold a leadership position in his/her Unit.
Unit Leaders name __________________________________________________
Home Phone # (______) ____________________________
Mailing address _____________________________________________________
Work Phone # (______) ____________________________
City/State/Zip _______________________________________________________
E-mail ___________________________________________
Unit Leaders Signature (required) _______________________________________
Parent/Guardian authorization statement:
Place current photo here
The attached official BSA medical form is correct to the best of my knowledge. The person
herein described has permission to engage in all prescribed camp activities except as noted by
Please use picture the size of larger box covering address below
the family physician or me.
In case of emergency, I understand that every effort will be made to contact me. In the
Photo must be clear and in color and only the size of this box
event that I cannot be reached, I hereby give permission to the physician selected by the
Camp Director to order any necessary procedure and to secure proper treatment for the
Mail Completed Form with a NON Re-fundable $100.00
health of the participant as named on this form.
deposit by May 1
I hereby give permission to the Camp Health Director to give current prescribed
medications and or over the counter medications as approved by the family physician and
Iroquois Trail Council, BSA - NYLT
noted on the reverse side on the “Individual Medical Order”.
201 East Main Street
I give permission to the Iroquois Trail Council to photograph the above individual during
Batavia NY. 14020
activities and use such photographs as they relate to Scouting.
I also agree that an electronically copied signature on this form is as acceptable as the
Balance of $305 is to be paid by July 1st, 2016
original signature.
to avoid a $15 Late Fee and Relinquishing their
I give permission to the Iroquois Trail Council to experience an activity off of ITC Property
as part of the conference curriculum.
previously guaranteed spot to a waiting list candidate.
Parent/Guardian Signature: _________________ Date: _________


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