2010 Regional Assembly

* Contact Information

Name   

Address  City  State  Zip

Email Address  Phone  

Home Church

Please indicate by checking this box that you understand photographs that include you or your child could
be taken at this event and consent for their use in future promotional materials.

* Choose Registration Rate (at least one rate must be selected to process registration)

Regular Rate - $60
Retired Minister & Retired Minister's Spouse Rate - $40
Youth Rate (6th-12th Grade) - $30
Children's Program (K - 5th Grade) - No Fee
       Child's Name   Age     Child's Name   Age

Day Care Details

Day Care Needed (Birth - 5yrs)
          Child's Name   Age
          Child's Name   Age
          Child's Name   Age

Additional Opportunities

Saturday Morning Clergy Breakfast, Country Homes Christian Church
Adult - $2.00
Child (12 & Under) - $1.25

Saturday Evening Meal
Adult - $11.00
Child (12 & Under) - $6.00

Friday Pre-Assembly Mission Projects (Free)
I plan to participate!

Notes and Clarification

Please use this space to tell us about special physical or dietary needs you might have or to clarify selections.

* Total Fees: Please add the costs of your selections together.

My Total Make note of this number for the payment process.