Christian Youth Conference

Camper Information

First Name:

*

Last Name:

*

Address:

*

City:

*

State (abbrev):

*

Zip Code:

*

Phone Number:

- - *

Email Address:

*

Date of Birth:

*

Grade:

10 11 12 Out of High School *
(as of Sept. 2010)

Sex:

Female Male *

Year at CYC:

1 2 3 *

Desired T-shirt Size:

Small Medium Large XL XXL *

Name of Parent/Guardian:

*

Parent/Guardian Email:

*

Did someone who has already attended CYC encourage you to attend? If so, please list the name of the one person most responsible for encouraging you to attend:

(please enter only one name)

Church Information (if applicable)

Church Name:

Church Address:

Church City:

Church State (abbrev):

Church Zip Code:

Church Phone Number:

- -

Church Scholarship Amt:

(if applicable)

Name of Pastor:

Registration Fee Payment

I will pay the registration fee via credit card through PayPal.

The registration fee is being paid by another source.