Quinipet Service Weekend Registration

Please fill out one registration form per family. All lodging will be based on single gender housing in dorm style buildings.

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* 1. Participant Information #1

Name

Age

Gender

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* 2. Participant Information #2 (leave blank if not applicable)

Name

Age

Gender

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* 3. Participant Information #3 (leave blank if not applicable)

Name

Age

Gender

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* 4. Participant Information #4 (leave blank if not applicable)

Name

Age

Gender

If you have more than four participants in your family please contact Kate Akerman at kakerman@nyac.com

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* 5. Emergency Contact Information

Name

Phone Number

Email

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* 6. Do any of the above participants have any dietary restrictions? If yes, please explain

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* 7. Do any of the above participants have any special skills or areas of interest that they're interested in contributing to our Service Weekend? If so, please list. Ex: Gardening, power tool experience, etc.

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* 8. Tell us more about your connection to Quinipet

Camper

Staff Member

Family Camp

Church Affiliation (please specify)

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* 9. Quinipet Camp & Retreat Center ________ have permission to use photographs of all above listed participants in any promotional and social media postings.

Does

Does Not

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* 10. I would like to pay the $60/person Quinipet Service Weekend fee by ______. This fee includes lodging, food, and supplies for the weekend.

Check/Money Order

Credit Card (AMEX, Visa, Mastercard) - please contact our office to process this charge over the phone