2026 Virlina District Bus Trip to NYC Registration Form
The bus trip is $1200.00 per person and is separate from the registration fee for National Youth Conference.  Please visit https://www.brethren.org/nyc/ to register for NYC.  
$200 non-refundable deposit is due on March 1, 2026 
The remaining balance is due on June 14, 2026.  
Please make your checks payable to the Virlina District with "Bus Trip" in the memo.
3402 Plantation Road
Roanoke, VA 24012

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Name  *
What congregation are you with? *
Participant Type *
Address *
Phone Number  *
Email  *
If youth, provide Youth Advisor name *
If youth, provide parent/guardian name.
If youth, provide parent/guardian phone number.
Emergency Contact Name *
Emergency Contact Number *
Please provide your Health Insurance Provider and ID number for emergency purposes. *
Do you have any allergies or health concerns we should be aware of? *
Do you have any dietary restrictions? *
If youth, what grade in fall of 2026
For housing purposes   *
Roommate Name Request ( Roommates will be 2 to a room and must be the same sex. Youth participants and adults may not room together. Married housing is available. We will try to honor your request, but this is much easier if your roommate also chooses you.)
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