Full Name:

Email:

Address:

City/State/Zip:

Nickname:

Maiden Name :

Staff roles held:

Dates/Years as Camper:

Dates/Years as SDP/YLT:

Dates/Years as Staff:

Profession/Employer:

Contact numbers:

Relatives who attended PLYC – years?:

2% Club (y or n):

Spouse/Partner:

Kids (names/ages):

How you would like to be involved?: