REGISTRATION FORM
MORAVIAN YOUTH CONVO 2017
JULY 1-6, 2017
Washington, D.C. * University of Maryland
A gathering of Moravian Youth for the purpose of Building Community,
Spiritual Formation, Mission Engagement, and Fellowship.
Participants must have completed grades 9 through 12 in 2017.
Chaperones must be at least 21 years old
and be approved by the Convo 2017 Planning Committee.
Payment information for all participants: Total participant cost is $800 (US)
Total Chaperone cost is $650 (US)
Fee includes
· Meals beginning with Dinner on July 1th through Breakfast on July 6th
· Housing July 1st – July 6th
· Travel once you arrive in the Washington D.C. area
· Program
· Service Mission Opportunity
· Tuesday Evening Entertainment
· Convo 2017 T-Shirt
Additional Expenses - Personal expenses not covered by the registration fee
· Travel to and from Washington, D.C.
· Spending Money
· Offering
· Replacement of Lost Metro ($50.00) or
o Lost Room Key Cards ($75.00)
Send the non-refundable deposit of $300 (US) made payable to “Convo 2017” along with completed registration pages 1 - 3 to:
Convo 2017
PO Box 1245
Bethlehem, PA 18016-1245
Payment Deadlines:
January 31, 2017: Deadline for registration and $300 (US) non-refundable deposit.
(Please note that if our Convo fills up before this date, you will be placed on a waiting list.)
February 28, 2017: Second payment of $250 (US) is due.
March 31, 2017: The balance of $250 (US) is due.
Personal Information:
Name_______________________________________________________________________ Gender ___ M ___ F
Street ____________________________________________________________________________________________
City __________________________________________ State/Province __________ Zip/Postal Code ______________
Country _________________________ Email address: ___________________________________________________
Home Phone ( ) _______________________ Cell Phone ( )_________________________
Birth date __________________________ Age ____________ Year Completed in High School ____________
Mother’s Name ________________________________ ________________________________________________
Home Phone (if different) Cell Phone
Mother’s Email_____________________________________________________________________________________
Father’s Name ________________________________ _________________________________________________
Home Phone (if different) Cell Phone
Father’s Email_____________________________________________________________________________________
Church Affiliation ______________________________ Congregation _______________________________________________
Roommate Request: 1. __________________________________
T-Shirt Order Form:
Each participant will receive one T-shirt as part of their registration fee. If you want to order extras the cost will be $12.00 each. Payment must be sent with the registration form. Select quantity and size of t-shirt(s) ordered.
___ Small ___ Medium ___Large ___ X-Large ___ XX-Large ___ Total # of T-shirts (including free t-shirt)
Amount paid for additional T-shirts ($12.00/shirt after 1 free shirt) $ __________
Tuesday Night Entertainment Options
On Tuesday evening we will take a break and enjoy an evening of entertainment. We are looking at three different options available, attending a Minor League Baseball Game, enjoying a night of local Theatre, or attending the fireworks on the national mall. The cost is included in your registration fee. What your preference? Please select one:
_______Minor League Baseball Game ________Theatre ________ Fireworks on the Mall
Registration Form page 2
Code of Conduct:
We expect each participant and staff member to conform to these rules of conduct.
o No possession of alcohol or drugs
o Smoking will be restricted to the designated areas
o No participant may leave the Convo group unless given permission to do so by the Convo Directors
o No weapons, fireworks, lighters, or explosives
o No offensive or immodest clothing
o Single Brethren and Sisters should respect the other’s need for privacy
o Participation with all group activities is expected
o Respect personal property of others
o Respect buildings and grounds of the buildings that we will visit
o Respect participants and staff
o Respect and comply with event schedule
o Cell phones should be used only in case of emergencies
Participants who fail to comply with these expectations may be sent home at their parents’ expense.
Health History - Please complete so that health providers can be aware of your needs.
List any pre-existing medical conditions: List all current medications:
List any disabilities: □ Wears glasses □ Wears contact lenses
List all allergies to food, medication or environment: List any dietary modifications:
List any major illnesses during last 12 months: Date of last tetanus shot/booster: ________________
Should activities be restricted for any reason? Please explain
I, the participant, have read the rules of conduct and reviewed my health history as listed above. I agree to abide by these rules and any stated health limitations listed.
____________________________________________________ __________________
Participant Signature Date
Registration Form page 3
Medical Insurance Information*
Insurance Carrier: ______________________________ Person to notify in case of emergency:
Name Policy Issued to: __________________________ ____________________________________________
Identification #: ________________________________ Relation to Registrant: _________________________
Group #: _____________________________________ Home Phone: ________________________________
Phone # on back of card for coverage and claims Work Phone: ________________________________
information: _______________________________ Cell Phone: _________________________________
*Please provide a copy, front and back, of your insurance card.
Emergency Medical Authorization - The purpose of this form is to authorize the provision of emergency medical treatment should you become ill or injured while under church authority. This authorization does not cover major surgery unless the medical opinions of two licensed physicians or dentists, concurring in the necessary surgery, are obtained prior to the performance of such surgery.
I hereby give my consent to the physician selected by the director of the Moravian Young Adult Convo 2017 to hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for ______________________________________.
(Participant’s printed name)
___________________________________________ ___________________
Participant Signature participant is over 18 years of age) Date
_______________________________________ _________________________ ___________
Parent / Guardian Signature (if participant under 18 years of age) Printed Name of Parent / Guardian Date
Release of Liability - Every participant or participant’s guardian must sign.
By submitting this form I allow the release of my name as part of an information database for Moravian Church-Northern and Southern Provinces (MCNSP)-related entities, and that photos/videos produced by Moravian Youth Convo 2017 become the property of the MCNSP and can be used for MCNSP-related purposes and publicity. I hereby freely grant to Moravian Youth Convo 2017 permission to publish photographs taken of me during Convo 2017 for advertising, Internet, and internal communication purposes.
I hereby confirm that I have voluntarily chosen to participate in the Moravian Youth Convo 2017 planned and arranged by the MCNSP for July 1-9 in Washington, D.C. and at the University of Maryland in College Park, Maryland. I am aware that the Moravian Youth Convo 2017 presents risks of personal injury and property loss or damage to participants. I expressly and voluntarily assume all such risks that may result from my participation in the Moravian Youth Convo 2017.
I hereby release the Moravian Church-Northern and Southern Provinces, its agents, affiliates and successors from all liability for injury, death or other loss or damage resulting from my participation in the Moravian Youth Convo 2017. I have read this agreement and release and fully understand its contents. I sign it of my own free will.
___________________________________________ ___________________
Participant Signature (if participant is over 18 years of age) Date
_______________________________________ _________________________ ___________
Parent / Guardian Signature (if participant under 18 years of age) Printed Name of Parent / Guardian Date
Registration Form page 4
Travel Information:
We are asking all participants to arrive at the University of Maryland in College Park, Maryland on July 1st between the hours of 1:30PM and 4:30PM. Dinner will be served at 6:00 PM followed by our opening worship and orientation program.
Please let us know when and how you plan to arrive and depart the Washington, D.C. area (this information can be sent in later when you make your final travel arrangements). If you are traveling by air, please try to book your flight either into the Baltimore/Washington International (BWI), or Ronald Reagan Washington National (DCA) airports.
Arrival Date ___________ Time _____________
Airport ____________
Airline (name) ________________________________ Arrival Flight # ______________
Departure Date _________ Time _____________
Airline (name) ________________________________ Departure Flight # __________________
Will you need to be picked up at the airport? _________
If you are not flying, please describe travel plans and any needs: ________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Send this page (page 4) of the registration form with the final payment of $250 (US) made payable to “Convo 2017” to:
Convo 2017
PO Box 1245
Bethlehem, PA 18016-1245