Young Adult Winter Retreat 2012

Contact Information

First Name

Last Name

Gender MaleFemale

Permanent Address

Address Line 2

City

State

Zip

Home Phone

Cell

College Address

City

State

Zip

Birthdate example - 01/18/1979

College Year Now

Meeting/Church you attend If you do not attend a Friends Meeting simply choose "Church/Meeting."

Medical Insurance Company

Phone Number

Policy Holder

Policy Number

Doctor's Name

Doctor's Phone

Medicine Applicant is using under Doctor's orders

Allergies or other health problems

Emergency Contacts

Contact 1

Name

Phone

Contact 2

Name

Phone

Early Registration: $50

Registration after January 21st: $60

How do you plan to pay the registration fee? Mail CheckPay Online

Please list the last 4 digits of the Visa or Mastercard you will use to make the online payment.

The above information will help us make sure your payment is credited to the correct account.

Online payment will be accepted after your registration is submitted.

Checks should be made out to "NCYM" with "YA Winter Retreat" in the memo line and mailed to:

NCYM
4811 Hilltop Rd.
Greensboro, NC 27407