Northwestern College campus

LYF Registration

January 28 – 30, 2022

Register by Jan. 15.

PERSONAL INFORMATION

Please provide the following information.

First name

Last name

Preferred name

Gender

Student phone

Parent phone

Date of birth

High school name

High school graduation year

Address

Address line 2

City

State

ZIP code

Student email

Parent email

Church name

Name of person(s) you’d like to room with at LYF (if known)

List any dietary restrictions

List any physical limitations

T-shirt size

REFERENCES

Reference #1

Please provide the name of a pastor or youth leader who can recommend you for this program.

First name

Last name

Email address

Phone number

Relationship to you

Reference #2

Your second reference may be a different pastor or youth leader or may be a teacher, mentor or friend. (Neither reference should be a family member.)

First name

Last name

Email address

Phone number

Relationship to you