Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Child InformationCamper Name *FirstLastDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name of School *Grade *Known Allergies: *Parent/Guardian InformationName *FirstLastEmail *Phone *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmergency ContactName *FirstLastPhone *Relationship To Camper *Medical Concerns *Signature *Clear SignatureI give permission for J.Y.S.L.A to obtain emergency medical treatment, including emergency transportation for my child if I cannot be reached immediately. I aggree to be responsible for any emergancy medical expenses incurred. (If oarent/gaurdian/representative refues to sign, instructions must be attached stating what procedure the facility is to follow in an emergency.)Printed Name of Above Signature *Authorized Alternate *Please designate an authorized alternate if you cannot pick up your child. DESIGNEE MUST BE AT LEAST 18 YEARS OR OLDER AND WILL BE REQUIRED TO PRESENT A VALID PICTURE ID.Who Cannot Pick Up Child? *For the safety and security purposes of your child, is there anyone who DOES NOT have permission to pick up your child? Submit Once you submit your form above, please click the Camp Payment button to submit your payment. Camp Payment About JYSLA Quick Links Home About Knight Life Our Mission Our Sponsors FAQ Contact Us Donate Now Knight Life Sign Up Contribute Donate Now Become a Sponsor FollowFollow