First Name

Last Name

Address

City

State

AK   AR   AZ   CA   CO   CT   DC   DE   FL   GA   HI   IA   ID   IL   IN   KS   KY   LA   MA   MD   ME   MI   MN   MO   MS   MT   NC   ND   NE   NH   NJ   NM   NV   NY   OH   OK   OR   PA   RI   SC   SD   TN   TX   UT   VA   VT   WA   WI   WV   WY   PR

Zip code Example: xxxxx or xxxxx-xxxx

E-mail Example: nyac08_gb@brethren.org

Re-enter e-mail

Day phone Example: xxx-xxx-xxxx

Evening phone Example: xxx-xxx-xxxx

Sex	Choose...   Female   Male

Birth date Example: mm/dd/yyyy Please note that if your day or month is only one digit, you must enter a leading zero (i.e. 03 for March)

District Name

Congregation

Congregational Code

Emergency contact name

Emergency contact phone Example: xxx-xxx-xxxx

Room preference

Choose...   unmarried   married

Roommate preferences Please note that each room will house six people total. If you selected unmarried, please list at least one other person with whom you would like to room. If you selected married housing, please list at least one other couple with whom you would like to room. We will try to honor your request, especially if made by both parties, but cannot guarantee it.

I am willing to help lead worship

I am interested in participating in the NYAC choir

I am interested in participating in a service project

If you have gifts that you think might be beneficial to the NYAC community, please describe briefly.

I would like to participate in community groups intended to enhance my NYAC experience by allowing time to reflect and process with my peers.   I would like to be in a community group with NYAC participants of various ages.   I would like to be in a community group with NYAC participants of similar age to me.   I would be willing to be a community group leader.   Please exclude me from community groups.

Language interpretation Please specify language in notes section below   Hearing impaired   Visually impaired   Wheelchair   Vegetarian   Dietary needs Please explain in notes section below   Other special needs Please explain in notes section below

Special Needs Notes

Allergies   Medication   Chronic illness

Medical Information Notes

A minimum of a $150 deposit must be made at this time. Please enter the deposit amount you will be sending.

Balance Due by June 1:

Check this box if you would like the NYAC Office to send a letter to your congregation requesting financial support for a portion of your registration fee.

How many previous Young Adult Conferences have you attended (including NYAC 2004)?

Check this box if you are not  willing to have your name, contact information, and district released to other registered NYAC participants for the purpose of coordinating travel arrangements.

 

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