MARYDALE RETREAT CENTER - ERLANGER, KY

REGISTRATION FORM (Please print and complete)

Mail to: Herman Kamlage, 1200 Highway, Apt. 416, Covington, KY  41011

Name: ______________________________________ Name tag: _____________________

Address: __________________________________________________________________

City: ______________________________________ State: ____________ Zip: __________

Phone: _____________________________ (Home) ___________________________ (Work)

only for the purposes of prioritizing registrations and for Healing Weekend

planning purposes.

************************PLEASE COMPLETE ENTIRE FORM***********************

( ); late night person ( ).

HIV Negative ( ), HIV Positive ( ), AIDS ( ) as of ___/___ (mo/yr)

This will be the ____________ AVNK-sponsored Healing Weekend I have attended.

Healing Weekend. You have my permission to give my phone number to others

in my area who may need a ride.

My ethnic background is ________________________.

Men ( ) Mixed ( ) Caregiver ( )

a confidential list that will only be distributed to facilitators and

participants at the weekend.

the confidential list.

______________________________________

( ) I am a vegetarian.

( ) Medication I am currently taking:

________________________________________________

( ) Medical complications I have experienced in the last 6 months:

________________________

( ) I have special needs: ( ) Refrigeration ( )

______________________________________

In case of over enrollment, persons with AIDS or those who are HIV Positive

will be given preference.

Relationship: ____________________________________

Phone: (Home) ( ) _______________________

          (Work) ( )________________________

Phone ( ) ___________________________

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small portion of the actual cost to present the weekend--the approximate

cost is $125.00.) There are three possible payment plans:

( ) I have enclosed a check for $45.00 made payable to AVNK.

( ) I want to attend, but I can't afford to pay the entire amount on my

own. I have enclosed a check for $25.00 made payable to AVNK, and I am

requesting a partial scholarship.

( ) I want to attend, but I can't afford to pay the registration fee on

my own. I request a scholarship to pay ALL of the cost.

( ) I want to help pay for another participant. Enclosed is an extra

$_______________.

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AIDS Volunteers of Northern Kentucky (AVNK) 72 hours before the weekend. I

realize that failure to do so may result in the loss of my registration fee

as well as prevent someone on the waiting list from attending.

2. MEDICAL RESPONSIBILITY: I understand that AIDS Volunteers of

Northern Kentucky (AVNK) does not assume responsibility for meeting my

medical needs and agree, in this regard, to hold AVNK, its staff,

employees, consultants, presenters, and/or volunteers blameless. I

understand that, while a nurse will be present during the Healing Weekend,

this nurse is only present to provide immediate assistance in a medical

emergency and is not present to serve as my primary care. I understand

that, if necessary, I will be transported to the nearest and/or most

appropriate medical facility for treatment and that the cost of such

transportation and treatment is my responsibility.

3. GENERAL LIABILITY: In all cases, except for willful negligence, I

hold AIDS Volunteers of Northern Kentucky (AVNK), its staff, employees,

consultants, presenters, and/or volunteers; other Healing Weekend

participants; and/or Marydale Retreat Center and its owners, managers, and

employees blameless for injury, illness, death, and/or all other maladies

which may befall me in connection with my participation in this Healing

Weekend.

4. CONFIDENTIALITY: I understand that I, and all other participants,

presenters, and organizers of this weekend, will protect the

confidentiality of all participants who are involved in this Healing

Weekend. I will not disclose the names of any participants who are

involved in this Healing Weekend. I will not disclose the names of any

participants to anyone not attending this weekend without the participants'

permission. Further, I understand and agree personal photography

(photographs taken by me or other participants or presenters) will only

take place with the permission of those being photographed and that such

personal photographs are not to appear in any publication or presentation

of any kind.

I have read this Agreement; I understand the Agreement; and by my signature

below, agree to it.

 _____________________________________ __________________

(Signature)                                                    (Date)

Please return completed form, along with your payment, by April 15, 2000 To: