THE GATHERING IN CALIFORNIA

FAMILY REGISTRATION FORM
Page 1

Note: This form is to be used only by families and friends of victims of the school violence incidents or those otherwise authorized by staff. You will be asked for identification when you come to the gathering in order to protect your privacy. Information you provide herein will be subject to verification as you authorize but will remain confidential with the staff. THIS INFORMATION IS STRICTLY FOR USE BY STAFF IN PROVIDING ACCOMODATIONS AND ORGANIZING THE EVENT AND THERE WILL BE ABSOLUTELY NO RELEASE OF THIS INFORMATION TO MEDIA OR SPONSORS.

Print a copy, sign, and mail to:
The Gathering
PO.BOX 17
Thurston,Or 97482

Last Name: ___________________________________________________________________________

First Names of Family Members attending: __________________________________________________

Street Address: ________________________________________________________________________

City and State: ________________________________________________________________________

May we contact you by phone?____________________________________________________________

Country: ______________________________________________________________________________

Relationship to victim (s):_________________________________________________________________

Survivor(brief explanation)________________________________________________________________

Lodging Preferences:

Are you opposed to staying with a host family if host families can be arranged? Yes No

Do you need financial assistance with arranging a hotel/airfare if available Yes No

explain___________________

If so, what are your room preferences? (smoking/nonsmoking, king/queen/full bed, etc.)______________

Do you need special accommodations from the airport or at the hotel? (wheelchair, special van, first floor room, etc.) _____________________________________________________________________________

What T-shirt sizes do you need? ___________________________________________________________

Who in your family/group wishes to speak at the forum? ________________________________________

Comments/other needs/feedback:

Click here for signature and mailing instructions (page 2)

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