2023 Liberty Symposium Tuition and Registration

Full Name: (required)

Email: (required)

Birth Date: (required)

Gender: (required)

malefemale

Address: (required)

City: (required)

State: (required)

—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyoming

County: (if you live in Idaho)

—Please choose an option—AdaAdamsBannockBear LakeBenewahBinghamBlaineBoiseBonnerBonnevilleBoundaryButteCamasCanyonCaribouCassiaClarkClearwaterCusterElmoreFranklinFremontGemGoodingIdahoJeffersonJeromeKootenaiLatahLemhiLewisLincolnMadisonMinidokaNez PerceOneidaOwyheePayettePowerShoshoneTetonTwin FallsValleyWashington

Zip Code: (required)

Primary Phone Number: (required)

Mobile Phone Number: (If Different)

Current School Grade Level: (required)

—Please choose an option—1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeCollegeNot in schoolOther

School Name and City / State of School: (required)

If under 18 at the start of the academy, do your parents approve of this application?: (required)

YesNoI'm 18 or older

Parent's Info

(if you are under age 18)

Parent's Full Name:

Parent's Email:

Parent's Primary Phone Number:

Housing

—Please choose an option—I will provide my own housingI will be staying at Boise Bible College

Roommate Request

Indemnity Agreement:

I will not hold or attempt to hold Northwest Liberty Academy liable for any loss, damage, or injury to person or property caused by any act or neglect of other persons, or caused in any manner other than the willful or negligent act of Northwest Liberty Academy, its agents and employees, and will indemnify and hold Northwest Liberty Academy harmless from any liability for damages or claims against Northwest Liberty Academy arising out of or in any way related to any such loss, damage or injury. I release Northwest Liberty Academy, including its trustees, employees and agents, from me or my child’s physical injury, including death, or illness while at the activity. I/We will assume the risk associated therewith, whether known or unknown to me/us at this time. This release is also intended to include all claims of my family, estate, heirs, personal representatives or assigns.

← Check ONLY if you agree to the Indemnity Agreement.

Authorization for Treatment:

In the event of a medical emergency, I understand that NWLA will try to contact me ASAP and I hereby give permission to Northwest Liberty Academy to secure and administer treatment and to maintain and/or release any medical records necessary for insurance purposes as outlined under the HIPAA regulation, and to provide or arrange necessary related transportation for the above named person. I further state that the above named person is in good health and capable of participating in academy-related activities and, if necessary, will tailor his/her activities to those within the bounds of his/her physical health. I recognize that any medical treatment that is provided to the above named person while attending Northwest Liberty Academy will be paid for by my medical insurance company and I guarantee payment for services not paid by insurance.

← Check ONLY if you agree to the Authorization for Treatment.

Photo Release:

I hereby grant Northwest Liberty Academy permission to use, reproduce, and/or distribute photographs, films, video and sound recordings of me or my child without compensation or approval, for use in materials created for purposes of promoting the activities of Northwest Liberty Academy, including the Internet.

← Check ONLY if you agree to the photo release.

Food Allergies and/or Dietary Restrictions:

Returning Students

As a returning student I would like to be a Youth Ambassador

New Students
Please attach two letters of reference and a profile picture of yourself:
(Letters of reference required for students 12-18 yrs only. Not required for returning students.)

Letter of reference #1

Letter of reference #2

A photo of you

If you have a sponsor who has paid part or all of your tuition, please include their information below:

Sponsor Name

Sponsor Phone Number

Sponsor Email

Amount Paid by Sponsor

Additional Information

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