June KCC 2011 Weekend Theme is “Awareness, Choice and Connection”

June 3-5, 2011 at Camp Jewel Colebrook, CT
Registration Form
(Please note: Last day to register is Friday, May 27th)

Name:____________________________________________________________

Address:__________________________________________________________

City: __________________________ State: ______________ Zip _________

Phone: ________________________ Cell: _________________________

Email: ________________________________________________________

I am vegetarian: Yes / No (Please circle one)

My special dietary needs are: __________________________________________________________________
(We will accommodate as best we can)

Cost for the KCC Conference:
_____Full Weekend Conference (Adult) $184.00
_____ Full Weekend Conference
(under 10 years of age) $87.00
_____Saturday only $74.00
_____2011 Membership fee $10.00
(If not already paid. Required for all adults)
_____Scholarship Donation
to support colleagues (voluntary) _______

TOTAL ENCLOSED: _____________

By May 27th, 2011, please return your registration form and check made out to KCC to:
Doug McDonnell
849 Union Street
Schenectady, NY 12308