2019 Common Threads - Advisor Registration Form

Please complete all questions fully. All information will be kept strictly confidential and will only be shared within CANDLE. No identifying information will be disclosed outside of CANDLE.

Feel free to contact us with any questions you have: jtyler@candlerockland.org.

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* 1. Advisor Information:

Name:

School / Organization:

Title:

Street Address:

City/Town:

State:

ZIP:

Work Phone:

Email:

Cell Phone:

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* 2. Can we text you as well as call you if necessary?

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* 3. Do you have a smart phone with a data plan?

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* 4. Would you like us to send you information about future programs?

Yes

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* 5. Emergency Contact Information:

Name: *

Relation to You: *

Cell Phone:

House Phone:

Work Phone:

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* 6. Are you a mental health professional (e.g. a social worker, therapist, psychologist, etc.)?

Yes

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* 7. IF YES - Would you be willing to volunteer as a "support person" at Common Threads?

Yes (Jay will talk to you more in depth about this role)

Maybe (You will be sent information regarding this role)

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* 8. Additional Needs:

	Yes	No
Do you need a transmitter and receiver to aid in hearing?	Do you need a transmitter and receiver to aid in hearing? Yes	Do you need a transmitter and receiver to aid in hearing? No
Do you need an ASL interpreter?	Do you need an ASL interpreter? Yes	Do you need an ASL interpreter? No
Do you need mobility assistance?	Do you need mobility assistance? Yes	Do you need mobility assistance? No
Do you have any health concerns of which you want CANDLE to be aware?	Do you have any health concerns of which you want CANDLE to be aware? Yes	Do you have any health concerns of which you want CANDLE to be aware? No
Do you have any food allergies or dietary restrictions?	Do you have any food allergies or dietary restrictions? Yes	Do you have any food allergies or dietary restrictions? No

Other (please specify)

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* 9. If you chose "Yes" that you have health concerns you'd like us to be aware of, please tell us here:

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* 10. If you chose "Yes" that you have food allergies or dietary restrictions, please tell us here:

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* 11. GROUP INFORMATION:

Name of Group You Are Advising:

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* 12. Name of Co-Advisor (if relevant):

NOTE: For every 6 youth, you MUST have 1 Advisor. If you have more than 6 youth, please ensure your group will bring another advisor or contact the Youth Pride Coordinator - youthpride@candlerockland.org. Your Co-Advisor must still register and pay, unless you have discussed your situation with the Youth Pride Coordinator.

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* 13. Please give us a list of names of the students you'll be bringing:

NOTE: If your Co-Advisor already registered with the names of the youth you'll be bringing, you don't need to retype that here. Just type "Co-Advisor Completed" in the box. Thank you!

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* 14. REGISTRATION FEE PAYMENT:

The registration fee for Advisors for the Common Threads retreat is $160. That covers meals for the entire weekend, supplies, lodging, and access to our Common Threads Professional Development Mini-Conference (which runs concurrently with the Youth Empowerment Retreat).

Payment options and information can be found here: http://www.candlerockland.org/commonthreadsregistration/

CANDLE also provides limited scholarships for youth who cannot afford the full registration fee. If you would like to contribute to our Common Threads Scholarship Fund for Youth, consider increasing the amount you pay for your registration fee as a donation.

Please check the Payment Arrangement that applies to you:

I will pay the full registration fee of $160.

I will pay the full registration fee of $160 and add an additional donation for the Common Threads Scholarship Fund.

I have spoken directly with the Youth Pride Coordinator about an alternative payment arrangement.

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* 15. Will you pay online or send a check/money order to CANDLE?

I will pay Online. (Pay online here: http://www.candlerockland.org/commonthreadsregistration/)

I will send or deliver a Check/Money Order to CANDLE - 120 N. Main St., #301, New City, NY 10956

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* 16. IMPORTANT: ONCE YOU HAVE COMPLETED THIS REGISTRATION FORM, PLEASE DOWNLOAD THE ADVISOR AGREEMENT FORM HERE: http://www.candlerockland.org/registerforct

YOU ARE NOT REGISTERED UNTIL WE RECEIVE YOUR PAYMENT & ADVISOR AGREEMENT

By typing "Yes" below you agree that you have read this statement.

Have you read this statement?

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* 17. How will you send the form to CANDLE?

PLEASE SEND ALL FORMS AND PAYMENTS BY 12/13/2017

Scan it and email it to us at jtyler@candlerockland.org

Fax it to us at 845-639-0951

Mail to us at:
CANDLE
120 North Main Street, #301
New City, NY 10956

Drop it off to Jay Tyler or Laurie Puca at CANDLE in person.

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* 1. Advisor Information:

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* 2. Can we text you as well as call you if necessary?

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* 3. Do you have a smart phone with a data plan?

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* 4. Would you like us to send you information about future programs?

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* 5. Emergency Contact Information:

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* 6. Are you a mental health professional (e.g. a social worker, therapist, psychologist, etc.)?

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* 7. IF YES - Would you be willing to volunteer as a "support person" at Common Threads?

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* 8. Additional Needs:

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* 9. If you chose "Yes" that you have health concerns you'd like us to be aware of, please tell us here:

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* 10. If you chose "Yes" that you have food allergies or dietary restrictions, please tell us here:

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* 11. GROUP INFORMATION:Name of Group You Are Advising:

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* 12. Name of Co-Advisor (if relevant):

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* 13. Please give us a list of names of the students you'll be bringing:

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* 15. Will you pay online or send a check/money order to CANDLE?

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* 17. How will you send the form to CANDLE?PLEASE SEND ALL FORMS AND PAYMENTS BY 12/13/2017

* 11. GROUP INFORMATION:

Name of Group You Are Advising:

* 17. How will you send the form to CANDLE?

PLEASE SEND ALL FORMS AND PAYMENTS BY 12/13/2017