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July 14 - 17, 2011 DISTRICT POW WOW

REGISTRATION FORM page 1 of 2

INSTRUCTIONS :

Copy this form, prior to filling it out. (you may need additional forms)

Type or print neatly.

Be sure to complete both pages of this form. (Use additional copies as required.)

Please keep a copy of the completed form and your check for your records.

Your pastor must sign each form used.

Make your Check or Money Order payable to:  “NY DISTRICT ASSEMBLIES OF GOD”  

COMPLETE ALL INFORMATION

Date ____  / _____  /  2011Outpost #_____________

Church______________________________________ Church Phone (_____) ______-_______________

Address___________________________________________________________________________

Sr. Commander_______________________________ Home Phone (_____) ______-______________

Address_____________________________________________________________________________

Church InsuranceCarrier___________________________________________________________      

Policy #_____________________________________________

Mileage to Camp- (check odometer) _________________(miles) X __________(# attending) =

PRE REG. and LATE PRE REG FEE of - $20. /PERSON MAILED with Pre-Registration form.

NON PRE REG. $130.00/person AT THE DOOR.

WE ACCEPT CHECKS, OR CASH AS PAYMENT.

COST:  $100/person PRE- REG. Due June 1       $120/person LATE PRE-REG Due June 15

     After June 15 or at the door you will pay $125.00/ person.

15% Discount for all Chartered Outposts and persons.

HAVE YOU INFORMED US OF THE NAME (S) OF PERSONS WITH SPECIAL FOOD NEEDS?  

AND HAVE YOU TOLD US OF THE FOOD CONCERN FOR EACH PERSON.

ADULTS/LEADERS WITH COMPLETED STAFF APPLICATIONS AND REFERENCE FORMS

1. _____________________________________________            6. _______________________________________________

2. _____________________________________________            7. _______________________________________________

3. _____________________________________________            8. _______________________________________________

4. _____________________________________________            9. _______________________________________________

5. ______________________________________________        10. _______________________________________________

           PASTOR’S APPROVAL OF ACCOMPANYING ADULTS

I, (print name) ______________________ serving as pastor of the above named church, give my approval for the adults named above to accompany the boys from our outpost on the 2011 New York District Pow Wow. They are of good reputation and meet the standards set forth by the New York District Assemblies of God for youth workers.

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