Registration

I am registering for the*:

Full Name*:

Mailing Address*:

Street/P.O. Box, Apt #, City, State, Zip Code

Daytime Telephone Number*:

Email Address*:

Number in Party*:

The number of people you are paying for.

Names of people in your party:*

List names of people being registered, separated by commas.

Do you require childcare?*

NoYes

How many children will need child care?*

The cost is $5.00 per child.

Names of children requiring childcare:*

List names of children, separated by commas.

How will you be paying?*

CashCheckCredit Card on fileCredit Card to be provided

Are you willing to help with the seminar?*

NoYes

In what capacity?

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