CYAM Retreat Registration Form

1
Prefix/Title* This field is required.Choose one
Please Select
Please Select
Mr.
Mrs.
Ms.
Rev.
Dr.
Rev.Dr
Bishop
Presiding Elder
2
Name* This field is required.
First Name
Middle Name
Last Name
Suffix
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Telephone Number* This field is required.
Please enter a valid phone number.
5
Alternate Telephone Number
Please enter a valid phone number.
6
Email* This field is required.
example@example.com
7
Episcopal District* This field is required.
Please Select
Please Select
First Episcopal District
Second Episcopal District
Third Episcopal District
Fourth Episcopal District
Fifth Episcopal District
Sixth Episcopal District
Seventh Episcopal District
Eight Episcopal District
Ninth Episcopal District
Tenth Episcopal District
Eleventh Episcopal District
8
Region
9
Local Church
10
District* This field is required.
11
Local Young Adult President
12
District Young Adult President
13
Please choose one* This field is required.
Young Adult
Young Adult Advisor/Director
Other
14
Medical SafetyPlease list any medical restrictions/accommodations that we should be aware of
Huge
Large
Normal
Small
Ok
Ok
15
Transportation* This field is required.Will you need a shuttle from airport to hotel?
YESNO
16
Additional RegistrationsWould you like to sponsor someone/others? If so, please list the number of how many and their names here:
1
2
3
Please choose your response
Option 1
Option 2
Option 3
First /Last Name
Please enter your email
First /Last Name
Please enter your email
First /Last Name
Please enter your email
17
Ad* This field is required.Would you like to purchase an ad in the souvenir booklet?
YESNO
18
VolunteerWould you like to participate in choir, dance, worship services? All post are open (usher, steward, stewardess, etc.)
Yes
No
Please choose your response
If yes, how would you like to volunteer?
19
How would you like to handle your registration payment?* This field is required.
Check
Debit/Credit Card
20
Registration Checkout
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ORDER SUMMARY
Total costUSD
Early Bird Registration
$100.00+Edit
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Additional RegistrationPlease only add this registration to your checkout if you are sponsoring additional persons for the conference
$100.00+Edit
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Quantity
Subtotal: $0.00
Total cost $0.00
21
Payment Methods
Debit Or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please click one of the PayPal options to complete payment and submit the form.
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