NCYC 2019 Adult Waitlist Form
Diocese of Columbus

This online form must be completed by the adult listed below and NOT another person on their behalf.

The Diocese of Columbus delegation to NCYC is currently at capacity, completing this form does not guarantee that you will be registered and able to attend, but it will add you to the waitlist. Individuals on the waitlist will be contacted on a first-come-first-serve basis to fill spots that open. This form asks all the questions of the registration form, so if you are able to fill a vacancy, you will not be required to complete a new registration form, however, you will be asked to complete an NFCYM waiver and send it back with full payment as soon as possible.
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Email *
Name of Parish/School: *
First Name of Adult Chaperone: *
(First) Name for Badge: *
Nickname or preferred name if other than first name.
Last Name of Adult Chaperone: *
Gender: *
Date of Birth: *
MM
/
DD
/
YYYY
Ethnicity (Optional):
Primary Language: *
Sweatshirt Size *
Trip Accommodations: *
Mailing Address: *
City: *
State: *
Zip code: *
Mobile Phone #:
Emergency Contact Name: *
Emergency Contact Phone Number: *
Chronic Conditions, special medical conditions, and/or physical limitations: *
(e.g. Epilepsy; Diabetes; Paraplegic; etc.)
Allergic Reactions: *
(e.g. Food; Medications; Plants; etc.)
Dietary Restrictions: *
Special Needs
Current Medication: *
The Participant is responsible for providing and taking all medication, prescription or non-prescription, required by the Participant.
Medical Insurance:
Policy Number:
Insurance Member's Name:
Insurance Phone #:
Family Doctor Name:
Family Doctor Phone #:
Safe Environment Compliance *
 Current/Valid Background Check
Safe Environment Compliance *
Completed Protecting God's Children Training
Release and Indemnification, and Code of Behavior *
I have read and agree to all the terms and conditions listed in the Release and Indemnification, and Code of Behavior found here: https://bit.ly/2tX78m4
NFCYM/NCYC RELEASE FORMS
If you are selected to fill a vacancy there will also be a required two-page NFCYM/NCYC Release Form to be completed and signed by the adult and submitted to the Diocesan Office of Youth and Young Adult Ministry as soon as possible.
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