NCYC 2019 REGISTRATION

*(Arch)diocese Name REQUIRED Please fill out this field.

*Region REQUIRED Please fill out this field.

*Parish/School Name, Town REQUIRED Please fill out this field. Please enter valid data.

*First Name REQUIRED Please fill out this field. Please enter valid data.

* Preferred Name for Badge (nickname) REQUIRED Please fill out this field. Please enter valid data.

*Last Name REQUIRED Please fill out this field. Please enter valid data.

*Participant Mailing Address (Please enter the address at which the person receives mail from the U.S. Postal Service.) REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Participant Email Address REQUIRED Please fill out this field. Please enter valid data.

*Participant Mobile Phone Number (If no cell phone number, enter 000-000-0000.) Please enter valid data.

*Emergency Contact Name ( Enter first and last name of contact. It is important to have an emergency contact name for ALL participants, regardless of age.) REQUIRED Please fill out this field. Please enter valid data.

*Emergency Contact Phone Number (Enter phone number including area code) REQUIRED Please fill out this field. Please enter valid data.

*Participant Type REQUIRED Please fill out this field.

*Gender REQUIRED Please fill out this field.

*Ethnicity REQUIRED Asian/Pacific Islander Black Hispanic Multi-Ethnic Native American White Other Not Known Please fill out this field.

*Primary Language REQUIRED Please fill out this field.

T-Shirt Size

Special Needs (Select all that apply from the options below) Sign Language Interpretation Needed Enhanced Listening Device Needed Large Print Program Needed Braille Program Needed Scooter/Wheelchair Rental Information Needed Early Stadium Access Needed due to Limited Mobility Assistance Needed Getting Between Stadium and Convention Center Low Gluten Host Needed

Youth: Grade at time of NCYC

Youth: Mother/Guardian First Name (If mother/female guardian is deceased, leave field blank.) Please enter valid data.

Youth: Mother/Guardian Last Name Please enter valid data.

Youth: Mother's address if different from child's Please enter valid data.

Youth: Father/Guardian First Name (If father/male guardian is deceased, leave field blank.) Please enter valid data.

Youth: Father/Guardian Last Name Please enter valid data.

Youth: Father’s address if different from child's Please enter valid data.

Adult: REQUIRED Please fill out this field.

Adult: Valid Background Check REQUIRED Yes No Not Known Please fill out this field.

Adult: Valid Training (VIRTUS) REQUIRED Yes No Not Known Please fill out this field.

How are you planning to travel to Indianapolis? REQUIRED My parish will travel on the diocesan bus. My parish will travel on their own. Please fill out this field.