LOMT 2012 Junior Staff Workshop Registration Form

All required fields are marked with an*

Guest Name: First* Last*
Gender*:

Birth Date: mm/dd/yyyy *
Home Mailing Address:*
Home City:* State:* Zip:*

Parent/Guardian Name First*    Last*
Home Church and City:
Daytime Phone:* ( ) -
Cell Phone: ( )- Evening Phone: ( )-
E-Mail address:* I request confirmation packet by:* Email Regular Mail

2012 Event:

Junior Staff Workshop - January 20-22, $90.00

Total Fee:*