Kairos Youth Workers Conference Registration

Kairos Youth Workers Conference Registration

Nov 18-20, 2022 in Lansing, Michigan.
Name*

First NameLast Name
Email*
example@example.com
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
Religious Denomination*

Youth Group Affilliation
Community/Youth Group Location*
Role in Youth Group (select all that apply)*

YG DirectorSmall Group LeaderPastoral SupervisorAdministratorOther

Emergency Contact & Medical Info
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*

Area CodePhone Number
Relationship to Registrant*
Do you have any physical impairments and/or limitations, or require special assistance to participate in the Youth Worker Training?*

YesNo
If yes, please provide details here. You will be contacted by a member of staff to discuss your specific needs.
Do you have any food/medical allergies?*

YesNo
If yes, please provide details here.

Payment & Travel Info
How are you planning on traveling to the YW Conference?*

DrivingFlyingDon't know yet
How are you paying for the YW Conference?*

I am payingMy YG is handling my payment

Michigan Resident$95.00

Non-Michigan Resident$40.00

Total $0.00

Payment Method
Credit	Express

Youth Group Affilliation