Registration Form

Primary Registrant

Title Full Name
Street Address City
State Zip/Postal Code
Country E-Mail
Phone - Home Phone - Cell

Parish Name, City & State
Vicar Name

Emergency Contact Information

Title Emergency Contact Name
Relationship Phone

Participant(s) Registrant

Title Name
Age Gender

# of Cots ($45 US Dollar each) # of Cribs ($15 US Dollar each)

If you are a doctor or nurse, are you willing to be part of the conference medical team?
If yes, provide cell number
Special Requests
Total: $0.00

Please read and sign below. Your submission indicates that you acknowledge, understand and agree to the following:

  • I agree that neither I nor anyone registering on this form will bring any alcoholic beverages or illegal substances onto the conference site.
  • I understand that images taken at the conference are the property of the Northeast American Diocese. I agree that these images may be used by the Northeast American Diocese for a variety of purposes without further notifying me.
  • I understand that I alone am financially liable for any damage done by my family members or myself to the facilities of the site.
  • I acknowledge and accept the responsibility for safety, liability, and medical insurance for myself, my family and those that I am answerable for, and do accept the restrictions. I also read and understood the rules and regulations stated on the next page of this form.
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