Nylt Individual Registration Form printable pdf download

Iroquois Trail Council National Youth Leader Training (NYLT) Individual Registration Form 2016

Scout’s last name

Unit

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

to:



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: _________

Nylt Individual Registration Form

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