53rd Weekend Registration Form 2012

Please print and return one form per person by May 30.

Name: _______________________________________________________________

Address:________________________________________________________

City __________________________________    Postal Code______________ 

Phone ______________________________  E-mail ________________________________

Parish __________________________________

All children K to Grade 5 will be involved in the "It's our world" elective

Required information if registrant is under 18 years:

Grade just completing _______ Name of accompanying adult__________________

Name of legal guardian ______________________________________________

Emergency contact (phone number) for legal guardian if not attending _____________________

How did you find out about 53rd Weekend?
Huron Church News/Anglican Journal Clergy/Parish Returning Friend

Some electives are limited in numbers so please choose 2 and register early.

1st choice: ____________________________________ 

Alternate: ____________________________________

Fees for programming and meals:

Adult		$135
Student		$110
Child (4 - 10)		$25

Accommodation at Huron University College:

Adult:		$60
Student (11-21):		$40
Child (4-10) in their own room:		$35
Child (4-10) with sleeping bag on floor of family member's room:		free
I will arrange my own accommodation		-

Elective material fees:

Banner making		$5
Art room		$15

Optional 53rd Weekend Shirts -- Order before April 30th!

Golf shirt (Adult)		$30
T-shirt(Mens, Ladies, Child)		$18
Shirt sizes: S M L XL XXL  Men's Ladies Child
Ball cap		$15

Pay by cheque, payable to the Diocese of Huron -- or -- by credit card:

Visa    Mastercard     American Express

Card Number: ______________________________ Expiry:   _______/_______ (month/year)

Signature:

If you are paying for more than one person: Total Enclosed $ _________

For whom else are you paying? ________________________________________


Accommodation:
I would appreciate a room with my family or friends (please list names):

__________________________________

I am attending for the 1st time
I am returning and I would volunteer. Contact me.
I am attending by myself and would appreciate a contact person / buddy
I will need an interpreter (sign language)
I WILL NEED LARGE PRINT

I have special needs (physical limitations)

_________________________________________________________

I have special food needs (allergies, etc)

__________________________________________________________

I have special medical needs (diabetic, etc.)

________________________________________________________


Direct questions, registration forms & payment to the registrar:
Alison Boyd
205 Pineland Court
Waterloo, ON     N2T 2S3
519-884-8841
arboyd @ alumni.uwaterloo.ca

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