Area IV Meeting Registration Form

Today's Date: (mm/dd/yyyy)
Your Name :
If you are filling this out for a group, including yourself, you will find space to list each person below on this form..
Middle (name or initial):
Last Name:
I prefer to be contacted by:
Home Phone Number:
Cell Phone Number:
Your Church:
Church Name: (if "First Baptist", include name of city or town)
Please list All additional family members being registered with you on this form. If age 18 or younger include age. (for example: sam; melissa, 8; tony, 17. Thank you.
Total Adults (age 19 and over, listed - include self):

Total Adult Registration Fees Amount @ $15 per adult.
$ (number only, no $ or decimals)

Child Care:
Do you need child care?
Total number childcare needed for ages birth to 3:
Total number childcare needed for ages 4 - 7:
Total Number ages 8 - 18
Total ages 8 - 18 Fees Due @ $5 per .
$ (number only, no $ or decimals)
Total Registration Fees Payable (adults and those ages 8 - 18)
$ (number only, no $ or decimals)
How will you pay?

(After you send this form, a page will open with links to the credit card form and address to send your check or money order.

1. Review the information you entered for accuracy.
2. Then click on "Send" to register.

Registration is completed when your information AND payment have been received by the registrar.