Registration Form: The Ohio Episcopal Celebration at Kenyon

Register and Pay Online—Credit Card Payments Must be Done Online

or

Please make copies of this form and fill out one form for each person attending the conference, including one for each child. Mail the completed forms, along with the check for the total conference fee made out to Ohio Episcopal Celebration at Kenyon, no later than June 10, 2009 to:

Treasurer Kenyon 2009

The Diocese of Ohio

2230 Euclid Ave

Cleveland, OH 44115

Last Name ______

First Name ______

Address ______

City ______State ______Zip ______

Home Phone (______)-______

Work Phone (______)-______

Email ______

Check all that apply:

Male ______/ Child (12 & under) _____ / (Age______)
Female ____ / Teen (13 to 18)______/ (Age ______)
Adult ______/ Preschool/Infant ____ / (Age ______)

Tee Shirt Purchase @ $ 12.00 each Yes ____ No ____

Shirt Size (Children S, M, L or Adult S, M, L, XL or XXL)

Single Room Requested? Yes ____ No ____

Roommate(s) (Provide full name(s)) ______

______

Scholarship requested? (Request mailed separately) Yes ______No ______

Special Needs ______

Transportation needed on campus? _____

Dietary Needs ______

Preschool Childcare? Yes ______No ______

Would you like to help with worship? Clergy ______Lay ______

Scholarship Application Kenyon 2009

Application due by May 26, 2009

Scholarships for conferees are available from the Dioceses of Ohio and Southern Ohio. Contact the person below, representing your diocese, for more information.

Complete the following form and submit it to the appropriate address shown below.

Name ______

Address ______

City ______State ______Zip ______

Home Phone (______)-______

Work Phone (______)-______

Email ______

How many scholarships? Adults ______Teens ______

Why are you seeking assistance?

How much will you provide? ______

(It is suggested that you consider seeking 1/3 of the fee from your parish, 1/3 from the scholarship, and 1/3 from yourself.)

Submit your application to:

Diocese of Ohio / Diocese of Southern Ohio
Susan McDonald
The Episcopal Diocese of Ohio
Trinity Commons
2230 Euclid Avenue
Cleveland, Ohio 44115 / The Rev. Canon Karl Ruttan
The Episcopal Diocese of Southern Ohio
Bishop’s Center
125 E. Broad Street
Columbus, Ohio 43215

The Ohio Episcopal Celebration at Kenyon

Community Living Agreement and Medical Form

Your signature and your parent or guardian's signature validate this agreement. It gives permission for your participation in The Ohio Episcopal Celebration at Kenyon and commits you to the norms and expectations of The Ohio Episcopal Celebration at Kenyon and makes you subject to logical consequences should you violate this agreement.

ALL YOUTH ATTENDING THE OHIO EPISCOPAL CELEBRATION AT KENYON WILL...

Participate fully in community activities (workshops, worship, meals, and leisure activities). / Not engage in sexual activities.
Comply with mandatory quiet times. / Not leave the evening youth program without notification and permission of the Youth Coordinator.
Respect the dignity of all human beings in both actions and words. / Not smoke. It is against the law for minors to purchase, possess or consume tobacco products in the State of Ohio, so minors will not be allowed to do so, even if parental permission was given.
Respect and care for the facility in which the activity is being held.
Not possess or use alcohol, illegal controlled substances, or weapons. / Abide by and respect the guidelines of the Conference.

If the youth will not be accompanied by his or her parent or Guardian, please provide the name of the adult who will attend the conference
and be responsible for the conduct and care of the youth.______

(Youth’s Signature)(Print Name Here)(Date)

(Parent/Guardian’s Signature)(Parent/Guardian’s Printed Name Here)(Date)

Medical Information Form (please print or type)

I, ______of ______,

(Printed Name of Parent or Guardian)(Printed Address, City, State, ZIP)

a parent and/or legal guardian, give consent and authorize an adult, in whose care the minor named above has been entrusted, to consent to X-ray examination, anesthetic, medical, surgery or dental diagnosis and treatment or hospital care, to be rendered to the minor under the general or specific supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act of a given jurisdiction, if there is insufficient time or inability to contact me. I will be liable and agree to pay all costs and expenses incurred in connection with such services rendered to the above named minor pursuant to this authorization.

This consent and authorization is made for the Episcopal Dioceses of Ohio and Southern Ohio and the Kenyon Summer Conference and said child being in our care or the temporary care of the aforementioned temporary custodian.

(Signature of Parent / Guardian) (Date)

(Mother's phone)(Father's phone)(Doctor's phone)

PLEASE BRING A PHOTOCOPY OF YOUR INSURANCE CARD

(Insurance Carrier)(Policy/Group #)(Phone Number)

(Additional Emergency Contact Name)(Relationship)(Phone Number)

List any medications currently prescribed and/or any other medical conditions, food or drug allergies.

Bring completed form with you to the Conference