Kairos Youth Workers Conference Registration

Kairos Youth Workers Conference Registration

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

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

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Date of Birth *

Month Day Year
Date
Religious Denomination *

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

YG Director Small Group Leader Pastoral Supervisor Administrator

Emergency Contact & Medical Info
Emergency Contact Name *

First Name Last Name
Emergency Contact Phone *

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

Yes No
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? *

Yes No
If yes, please provide details here.

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

Driving Flying Don't know yet
How are you paying for the YW Conference? *

I am paying My YG is handling my payment

Michigan Resident $ 95.00

Non-Michigan Resident $ 40.00

Total $ 0.00

Payment Method

Youth Group Affilliation