Registration: Earth Song - 7th - 12th grade (May 25, 2018 - May 27, 2018 )

USER INFORMATION
First Name: * 
Last Name: * 
Address: * 
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City: * 
State: * 
Zip: * 
Email: * 
Parents' names: * 
Parents e-mails: * 
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Phone: * 
Your Quaker meeting or other faith community:
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Birth Date: * 
select your current grade: * 
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Gender: * 
Note any other concerns we should be aware of (health, accesibility, etc.):
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FOOD: Check any of these restrictions that apply (you may explain details in the next box):
vegetarianveganallergy-specify belowno gluten
Explain any specific food needs or things that the cook should know:
1
The following information I have given here is new:
mailing addressphone numbere-mailfood needs
TRANSPORTATION: Would you like to be included on the carpool list? The list is sent to people who are on it.: * 
yes  no  
I am planning to arrive by train and would like to be on a list of people willing to share a taxi:
Hudson Amtrak (from NYC)  Albany Amtrak (from the west)  
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MONEY : The deposit amount will appear automatically on the confirmation page. You may change the amount by typing in what you want to pay at this time (above the minumum deposit).
I am using my individual annual subscription: * 
Yes  No  
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I am the authorized person to use my monthly meeting's subscription for this conference: * 
Yes  No  
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I would like the first time attender youth discount:
yes  
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Enter the amount of financial aid you are requesting from Powell House:
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Please note here anything else we should know.:
My monthly meeting will pay for my registration (You will not have to pay the deposit on the web site.):
Ithaca - youth conference  
Rahway- Plainfield - all ages  
other meeting will pay (put the meeting or committee name & the amount they will be paying in the comment box)  
Ooops, I clicked one of the above buttons and then it wouldn't un-click so this button says just ignore the other one.  
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I am making a donation to help offset the actual cost of youth conferences:
$25  $50  $75  $100  $125  
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The deposit amount will appear on the confirmation page. You may change that number on the confirmation page and pay any amount over the minimum. If you do not make the minimum deposit on the next page, then YOUR REGISTRATION WILL NOT BE SAVED. We won't even know you were here. You must call or email us if you are not going to pay the minimum deposit. ( If the amount in the deposit line is $0, then it WILL be saved. )

Powell House is the conference and retreat center of the 

New York Yearly Meeting of the Religious Society of Friends (Quakers).

Powell House
524 Pitt Hall Rd
Old Chatham,  NY
12136
phone  518-794-8811
fax     518-794-8815
Adult Program 
sharon@powellhouse.org
regina@powellhouse.org
Youth Program
chrisandmike@powellhouse.org