2019 Common Threads - Youth Participant 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.

**When you're ready to submit the form, hit the Done button on the bottom of the page once for it to go through.**

*NOTE: Legal name is for emergency purposes only. Please note that we will not use this name unless requested.*

Question Title

* 1. PARTICIPANT INFORMATION:

Legal Name: *

Preferred Name:

Group / School: *

Grade Level: *

Street Address: *

City/Town: *

State: *

ZIP:

Email Address: *

Phone Number: *

Question Title

* 2. Date of Birth:

Ex: 07/10/2014

Date

Question Title

* 3. What is your preferred method of contact?
(Please check all that apply.)

Phone (voice)

Phone (text)

E-mail

Question Title

* 4. Do you own a smart phone and have a data plan?

Question Title

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

Yes

Question Title

* 6. EMERGENCY CONTACT INFORMATION:

Please provide your parent's or guardian's contact information here:

Name: *

Relation to You: *

Cell Phone:

House Phone:

Work Phone:

Question Title

* 7. In case of emergency, which name and pronouns would you like for us to use when talking to your emergency contact? Is there anything else you would like for us to say?

Question Title

* 8. GROUP AND ADVISOR INFORMATION:

PARTICIPANTS MUST ATTEND WITH A GROUP AND/OR ADVISOR. If you do not have a group and/or Advisor - or you are unsure if your Advisor is able to attend, please get in touch with us as soon as possible.

We are willing to work with you until you have a group and Advisor with which to attend the weekend, but we must know right away.

Will you be attending with a group or organization?

I have a group to attend with.

I do not have a group to attend with.

Question Title

* 9. Name of group:
(If you don't have a group or you're unsure, type N/A.)

Question Title

* 10. Do you have an Advisor?

I have an Advisor.

I need an Advisor.

I'm unsure if I have an Advisor.

Question Title

* 11. Name of Advisor:
(If you don't have an advisor or are unsure, type N/A.)

Question Title

* 12. 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)

Question Title

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

Question Title

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

Question Title

* 15. REGISTRATION FEE PAYMENT:

The registration fee for the Common Threads retreat is $175. That covers meals for the entire weekend, supplies, and lodging.

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

PARTIAL SCHOLARSHIP: CANDLE also provides Partial Scholarships for youth who cannot afford the full registration fee. Please let us know below if you think you'll need a scholarship. If you have the resources and would like to help other youth attend Common Threads, 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 $175.

I will pay the full registration fee of $175 and add an additional donation to help provide Partial Scholarships.

I need a Partial Scholarship.

Question Title

* 16. I would like to be considered for a Partial Scholarship. I can afford to contribute:

$150

$125

$100

$75

Other (please specify)

*Please keep in mind that the more you can afford to pay, the more people we are able to help with scholarship funds.

Question Title

* 17. 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

Question Title

* 18. IMPORTANT: ONCE YOU HAVE COMPLETED THIS REGISTRATION FORM, PLEASE DOWNLOAD THE PARTICIPANT AGREEMENT & ADVISOR INFORMATION FORM HERE: http://www.candlerockland.org/commonthreadsregistration/

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

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

Have you read this statement?

Question Title

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

PLEASE SEND ALL FORMS AND PAYMENTS BY 12/14/2018. Forms received after 12/14/18 will be automatically wait-listed, and notified about available slots no later than the week of the retreat. No scholarships will be awarded for applications received after 12/14/18.

PLEASE NOTE: If you register and drop out after December 17th, there will be a 20% fee. After January 1st, 2019, a fee of 50% will occur. If you drop out after January 12th, a full fee will be charged.

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

Fax it us at 845-639-0951

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

Drop it off to the Youth Pride Offices at CANDLE in person.

Question Title

* 1. PARTICIPANT INFORMATION:

Question Title

* 2. Date of Birth:

Question Title

* 3. What is your preferred method of contact?(Please check all that apply.)

Question Title

* 4. Do you own a smart phone and have a data plan?

Question Title

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

Question Title

* 6. EMERGENCY CONTACT INFORMATION:Please provide your parent's or guardian's contact information here:

Question Title

* 7. In case of emergency, which name and pronouns would you like for us to use when talking to your emergency contact? Is there anything else you would like for us to say?

Question Title

Question Title

* 9. Name of group:(If you don't have a group or you're unsure, type N/A.)

Question Title

* 10. Do you have an Advisor?

Question Title

* 11. Name of Advisor:(If you don't have an advisor or are unsure, type N/A.)

Question Title

* 12. ADDITIONAL NEEDS:

Question Title

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

Question Title

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

Question Title

Question Title

* 16. I would like to be considered for a Partial Scholarship. I can afford to contribute:

Question Title

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

Question Title

Question Title

* 3. What is your preferred method of contact?
(Please check all that apply.)

* 6. EMERGENCY CONTACT INFORMATION:

Please provide your parent's or guardian's contact information here:

* 9. Name of group:
(If you don't have a group or you're unsure, type N/A.)

* 11. Name of Advisor:
(If you don't have an advisor or are unsure, type N/A.)