IOKDS CLERGY RENEWAL WEEK APPLICATION -2010
July 24 - July 31

Clergy Name____________________________________________________________

Spouse Name (If applicable)_______________________________________________

Please indicate if spouse is clergy

Spouse will also attend__________________Spouse will not attend_______________

Home Street Address_____________________________________________________

City__________________________________State____________ZIP______________

Home Phone_(______)________________E-Mail______________________________

Cell Phone___(_______)___________________

Clergy at____________________________________Position____________________

Denomination___________________________________________________________

This will be first time at Chautauqua________________________________________

Dietary Concerns: Diabetic___________________Vegetarian___________________

Food Allergies___________________________________________________________

Emergency Contact: Name________________________________________

Address______________________________________

______________________________________

Phone _(_____)________________

Signature___________________________________________Date________________

Sponsoring IOKDS Member Comments:

 

 

Signature____________________________________________Date_______________

Mail to: Nan R. Pointer, Vice-President/Spiritual Life Director, 4890 Hermitage Lane, Gloucester, VA 23061