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. Question Title * 1. Participant Information #1 Name Age Gender Question Title * 2. Participant Information #2 (leave blank if not applicable) Name Age Gender Question Title * 3. Participant Information #3 (leave blank if not applicable) Name Age Gender Question Title * 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 Question Title * 5. Emergency Contact Information Name Phone Number Email Question Title * 6. Do any of the above participants have any dietary restrictions? If yes, please explain Question Title * 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. Question Title * 8. Tell us more about your connection to Quinipet Camper Staff Member Family Camp Church Affiliation (please specify) Question Title * 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 Question Title * 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 Done