IOKDS CLERGY RENEWAL WEEK APPLICATION -2013
August 3 - 9, 2013

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: Betty Myers, Spiritual Life Director, 13407 East 51st Street, Kansas City, MO 64133-2631, or e-mail: pianobjm@aol.com.