Kairos CoMotion Registration Form
Please complete a separate form for each participant.
Copy as needed or download additional forms at www.KairosCoMotion.org

________________________________________________
Name		 Clergy   or   Laity   (Please circle)
________________________________________________
Address		 ______________________ / __________________
Daytime Phone                         Evening Phone
________________________________________________
City, State, Zip		  
_________________________________________
E-mail address		 __________________________________________
Fax number

1. WORKSHOP CHOICES: Indicate your 1st and 2nd choice, and 3 alternates. 

First Choice:      ________________________________________________

Second Choice:  ________________________________________________

Alternates:     1. ________________________________________________
                        2. ________________________________________________
                        3. ________________________________________________

2. SPECIAL ACCOMMODATIONS:

    Do you need child care? _________          Number of Children: __________          Ages: _________________

    Indicate any accommodations you require to enable your full and comfortable participation in this event.
    Please specify: ____________________________________________________________________________
    ________________________________________________________________________________________

   _____ I am willing to be designated as an Emergency Medical Responder during this event.

3. EVENT FEES: *does not include housing
A. Registration fee: $135 (must be postmarked by December 1, 2001)
A.  $__________

B. Late Registration: $185 (must be received no later than February 1, 2002)

($50 of the registration fee is non-refundable)
B.  $__________
A limited number of partial and/or full registration scholarships are available. For more information contact Amy DeLong, 715.463.2081 or lavenderloca@yahoo.com  
C. I would like to make a financial contribution to this and
     future projects of Kairos CoMotion
C.  $__________
D. Enclosed is a check for $__________ Total         $__________

 Sorry, no credit cards accepted.
Please make checks payable to: Kairos CoMotion, Inc.
and mail with this form to:
Ms. Margaret Talcott, Registrar
PO Box 7492
Madison, WI 53707