Northwestern College campus

LYF Registration

June 23–28, 2019

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

PAYMENT

Pay now Pay when I arrive on campus

Please provide the following credit card information.

Card number

Expiry date

Security code

For Visa, Mastercard, and Discover (left), the 3 digits on the back of your card.

For American Express (right), the 4 digits on the front of the your card

First name

Last name

Address

City

State

ZIP code

Total amount

$190.00
This is the amount that will be charged to your credit/debit card.