Registration: Quaker Youth Gathering - Rochester, NY (Oct 21, 2017)

USER INFORMATION
First Name:
Last Name:
Address:
1
City:
State:
Zip:
Email:
Phone:
Birth Date:
select your current grade:
1
Parents' names:
Parents e-mails:
1
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
Your Quaker meeting or other faith community:
1
Note any other concerns we should be aware of (health, accesibility, etc.):
1
TRANSPORTATION: Would you like to be included on the carpool list? The list is sent to people who are on it.:
yes  no  
Please note here anything else we should know.:
What are the concerns or issues that you suggest we have this group discuss or learn more about?:
1
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