Date __________________
Name: _______________________________________
_____ I affirm that I am at least 18 years of age.
Mailing Address: _________________________________________
City: _________________________________
State: __________ Zip Code: __________________
Phone: _________________________________
___ I affirm that I am a member in good standing of the church of Christ.
Congregation: ____________________________________
___ I have enclosed $10.00 for a NYC Annual Membership.
___ I have enclosed $_______ for _____ years of membership.
___ I have enclosed $200.00 for a NYC Life Membership.
I have read and understand Article II (Membership) of the Nebraska Youth Camp
By Laws as amended January 17, 1997.
Signature: _______________________________________