Roc the Diocese! 2023

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Start: Friday, April 28, 2023 at 5:00 pm

Ends: Sunday, April 30, 2023 at 12:00 pm

Where: The Y at Watson Woods, 9620 Dry Run Road, Painted Post, NY, 14870

https://rochesterymca.org/locations/ymca-watson-woods

Who: Anybody in 6th-12th grade

What:

*Music
*Games
*Small group time
*Campfire
*Opportunity to meet new people from around the Diocese!
*Lots of time outdoors

*Worship

Cost: $50

Scholarships available- contact Rev. Keisha and Mthr. Gretchen for more information. You will receive instructions for how to pay after you complete this registration form.

Registration Deadline: April 12

*Please complete this form for each youth attending.*

Youth Attendee Name *

Youth Attendee Email *

Attendee Date of Birth *

YYYY

Parent/Guardian Name and Phone Number *

Parent/Guardian Email *

Home Address (Street, City, Zip) *

Church Name and Location *

Age *

Gender *

Grade *

T-Shirt Size *

Dietary restrictions *

None

Other:

Required

Photo Permission: I give permission to photograph and record those named above and to use the images and sound in promotional materials/media for the diocese. *

Yes

Medical Information

Medical Care Permission: I give my permission for my child to attend Roc the Diocese, an overnight youth event sponsored by the Episcopal Diocese of Rochester. In the case of an emergency, I understand that every effort will be made to contact me. In the event I cannot be reached, I hereby authorize any necessary medical care and agree to pay all charges connected with such treatment, not covered by insurance. *

Yes

Please describe any medical conditions we need to be aware of (eg. asthma, allergies, etc.) *

Do you have any prescribed medical treatment or drugs that need to be taken during Roc the Diocese? (Note: all medications will be collected at check-in and will be administered by an adult at the necessary times)

Please describe:

Family Physician's Name and Phone Number *

Medical Insurance Carrier *

Policy/ID Number- PLEASE BRING A COPY OF YOUR MEDICAL CARD WITH YOU. *

Emergency Contact Person/ their phone number *

Do you have any other comments or concerns you would like to share with Retreat Staff?

If you have any questions, please contact Co-Conveners of Diocesan Youth Ministry

-Rev. Gretchen Ratterree: reverend@stmarknewark.org

-Rev. Keisha Stokes:revkeishastokes@gmail.com

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