IOKDS CLERGY RENEWAL WEEK APPLICATION -2012
August 4 - 11, 2012

Clergy's name__________________________________________________________________

Spouse's 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(s) _____________________________________________________________________

Signature__________________________________________________Date________________

Sponsoring IOKDS member comments______________________________________________

______________________________________________________________________________

______________________________________________________________________________

Signature___________________________________________________Date_______________

Mail to: Nan R. Pointer, Vice-President/Spiritual Life Director, 4890 Hermitage Lane, Gloucester, VA 23061, or e-mail: nrpointer52@gmail.com