EPISCOPAL DIOCESE OF LONG ISLAND

Youth Pre-Convention Conference


Sunday, October 20, 2019

3:00-6:00 PM at the Mercer School of Theology 

   65 Fourth St, Garden City, NY 11530

                                                                                               

Name of youth delegate*
Demographic Information: (Please check all that apply)* In keeping with the Church's desire for multicultural inclusivity, we are collecting demographic information of youth delegates to convention in order to share the diversity of our presence with the wider Diocesan Convention of Long Island. Please select as many categories as appropriate to describe your heritage. Thank you for providing this information.*
Youth delegate's home address*
For parents and guardians: The remainder of this form requests information for a medical release. By filling out the information below, you are giving consent for your youth to participate at this event and in the case of a medical emergency for the adults present to seek and provide medical assistance.*
I give full permission for my child to take the following over-the-counter drugs. Check all that apply.*
Parent/Guardian*
Parent/Guardian's address*
Additional emergency contact person*
Upon signing below and clicking the "Submit Form" button, I understand that by completing this online registration that I am signing a community agreement, a photo authorization release, and a waiver of liability. Please immediately save and/or print this document for your own records.*
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