Church Name *

Church Address *

Church Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Youth Contact Name *

Youth Contact Phone *

Youth Contact Phone

(###)

###

####

Youth Contact Email Address *

List ADULTS Attending -- MUST INCLUDE Name and Gender (M/F) *

List YOUTH Attending -- MUST INCLUDE Age/Grade - Name - Gender (M/F) *

Total Number Attending *

Checkbox *

Leader to Student Ratio 1:7 (Same Gender) Please check Total Attending Price Bracket

$85.00/person -- Group of less than 10

$75.00/person -- Group of 10 or more

Total Amount Due *

$

REGISTRATION DUE BY JANURY 15, 2018

If sending Registration Form by mail, send to: Rev James Blake, 406 Wood Street, Minneapolis KS 67467