Winter KCC Conference

Lifebridge Sanctuary, Rosendale, NY

January 21-23, 2011

Registration Form

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 $255.00

_____Commuter $165.00

_____2010 Membership fee (required for all adults) $ 10.00

_____Scholarship Donation to support colleagues _______

TOTAL ENCLOSED: _________________

By January 15, 2011, please return your registration form and check made out to

KCC, to:

Doug McDonnell

849 Union Street

Schenectady, NY 12308