Winter Watch 2006 Registration Form

This form is to be used for the Winter Watch Youth Gathering ONLY. Please use the Camp registration form for Camps. DATE: December 29 -30th, 2006

COST OF EVENT: 40.00

Registrations and checks are due not later than December 20, 2006. Checks should be made payable to “Trustees and Council.” If scholarship aid is needed, please contact the Diocesan Office prior to submitting registration form. MAIL TO: Diocesan Youth Gathering c/o Betty Williams Diocese of Kentucky 425 S. Second St., Suite 200 Louisville, KY 40202 NAME: _____________________ GENDER: ______ BIRTHDATE: ______________ AGE: _____

GRADUATION YEAR: ______ EMAIL ADDRESS: _________________

STREET ADDRESS: _____________________________________________________ CITY, STATE, ZIP CODE: _________________________________________________ HOME PHONE: _______________________ CHURCH: ________________________

SPECIAL DIETARY REQUEST: (Food allergies, vegetarian meals only, lactose intolerance, etc.) __________________________________________________

Participant’s Agreement I will not use tobacco, alcohol, illegal non-prescription drugs, inappropriate language, or inappropriate sexual behavior while attending this event. I also agree not to wander off beyond the boundaries defined, or leave my cabin without permission from an adult after evening curfew. I understand that if I choose not to comply with any of the above, my parents will be called, my priest notified and I will be sent home. Signature of Participant: ____________________________________ Signature of Parent or Guardian: _____________________________

For Clergy I offer my support to________________ as he/she attends this event. Scholarship Information (suggested: 1/3 parent 1/3 home church 1/3 Diocese). The priest, Sr. Warden or Youth Director must check with the Diocesan Office to obtain a scholarship for anyone 10 days prior to the event. No scholarship will be awarded if this is not adhered to. Enclosed is _______from the congregation; _______from parents or guardians and the Diocese will pay the additional 1/3. Checks from both parents and church should accompany each registration form. Signature of Clergy or Warden or Youth Director:_______________________________

Medical Information

Insurance Co. & Policy No. ________________________________________________ Names of regular medications, times given and amounts: ________________________ ______________________________________________________________________ Allergies: __________________________________________________________________________

Are there any emotional problems the leaders should know about? ________________ ______________________________________________________________________ In case of emergency notify: _______________________Phone #:________________ I give my child _______________ permission to be treated by a physician or nurse in case of accident or illness and if taken to an emergency room, I understand that I will be called at once. Signed: _____________________________________________