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NewStory Youth CIY MIX 2019 Registration
Dates: Monday, July 8, 2019 - Thursday, July 11, 2019

Location: Chapman University
One University Drive
Orange, CA 92866

Cost: $240*

*Sibling discount of $10 per additional child available
*Full Scholarships Available

STUDENT INFORMATION
First and Last *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Grade (going into for the Fall)
PARENT INFORMATION
Parent/Guardian First and Last Name *
Your answer
Parent/Guardian Contact Phone Number *
Your answer
Parent/Guardian Email *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone *
Your answer
INSURANCE
Health Insurance Company
Your answer
Policy Holder Name
Your answer
Health Insurance Policy Number
Your answer
Physician Name and Phone Number
Your answer
Allergies or Dietary Restrictions
Your answer
Check all that apply: *
Required
I have read the above and agree to its terms and conditions. Furthermore, should it be necessary for my child to return home due to medical, disciplinary, or otherwise, I hereby assume all transportation costs. *
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