Registration for Fall Sessions
Friday–Sunday, November 12–14, 2010
Flushing Meetinghouse, Flushing High School

Please return an individual registration form for each person attending, age 6 and over, by Monday, October 25.

Name ____________________________  Meeting ____________________
Address _______________________________________________________
City ________________________ State _______________  ZIP _________
Age (if under 19) __________
Home phone __________________  Work phone _________________
Cell phone (in case of weather or emergency only) __________________
E-mail address _________________________________________________
Housing: I will arrange for my own housing ________
I will be staying at the Flushing YMCA ________
Would like hospitality for: Friday night _______  Saturday night _______
Would like to room with _________________________________________
Can bring sleeping bag if needed ________
Special needs: Smoker _____  Stairs a problem _____ Allergies ______ 
Vegetarian ________  Other _____________________________________
Childcare needs: (for children under 6 years old)
Child’s name _______________________________________ Age _______
Child’s name _______________________________________ Age _______
Meal rates:  Please specify if vegetarian:    yes ____  no ____
Children (3–11 years) receive a 50% discount on meals; Children under 3 free
Friday potluck dinner
please let us know if you plan to attend		yes ____  no ____
Saturday
Lunch 	$ 10	$ ______________
Dinner 	$ 14	$ ______________
Sunday
Coffee & bagels (no charge, please let us know if you plan to attend) yes ____  no ____
Lunch at Flushing  $ 10  						$ __________
$15.00 registration fee to NYYM (ages 19 and older) 	$ __________
Add $5 Late fee (after October 25)
Contribution to NYYM Equalization Fund 			$ __________
TOTAL COST 					$ __________
Assistance requested from NYYM Equalization Fund 	$__________

TOTAL ENCLOSED 					$ __________
Transportation and/or other special needs (attach note if necessary):
____________________________________________________________________________________________________________________________
     **Parents will be responsible for any children not registered by October 25**

(Name) _____________________________ will participate in the Youth Program (6–11 age group ____      12–18 age group ____).
My parent/sponsor at Fall Sessions will be:
(Name): ______________________________________________________
Make checks payable to New York Yearly Meeting or use the PayPal link at www.nyym.org noting that it is for Fall Sessions
By postal mail, please return form and check to: Yonathan Dessalegn  65-40 108th St. #2A,  Forest Hills  NY  11375  917-972-0860  FlushingRegistrar@gmail.com