Lakulish Youth Camp & Summer Retreat Registration Form

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Event Timing: Thursday, June 29th through Sunday, July 2nd, 2023
Event Address: Lakulish Yoga and Health Retreat
8136 NC Highway 119 South
Mebane, NC 27302
Contact us at 1-336-421-0690 or lifemissionashram@gmail.com

Lakulish Yoga and Health Retreat

Applicant Full Name *

Permanent Address *

Home Phone *

Cell Phone *

Email *

Date Of Birth *

YYYY

Grade *

Gender *

Male

Female

Father's Full Name *

Emergency / Cell # *

Email *

Mother's Full Name *

Emergency / Cell # *

Email *

Health Insurance Company *

Subscriber’s Name *

Member ID *

Group ID *

Exp. Date *

YYYY

Full and complete liability release disclosure:

I___________________________________ , as natural parent and/or legal guardian of_____________________________________ hereby give my child permission to participate in Youth Camp and Summer Retreat organized by Life Foundation, a non-profit organization in State of North Carolina. My name and initials on this application typed below certifies that the information provided is true, accurate and complete.

Full Name *

Initials *

Submit

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