Registration Form

For Barb Shelton's Seminars

DIRECTIONS:

1)  Click to "Full Screen" and then print out this form.

2)  Fill in this form by hand. (Yes, the old fashioned way! Weird, huh?!?)

(Do NOT try to type it in here;   I don't have it set up to work that way.)

3)  EITHER:

A - Write out a check or money order

for the correct amount ($10/person or $15/couple) or...

B - Write your credit card info at the

bottom of this form.

4)  Mail the completed form (with payment if

paying by check or m.o.) to:

Name of Mom: ____________________________________________________________

My  [ husband / teen ]    [ __will   __will not ]  be attending with me on  Friday night.

My  [ husband / teen ]    [ __will   __will not ]  be attending with me on  Saturday.

(Teens do not have to pay, but we do need to know how many to set up for)

___ I have read Barb's Policy on Children at (her) Meetings and, whether I agree or not (and it's OK if I don't),

I will nonetheless comply.    (nicely  ;-) )

Address: ________________________________________________________________________

City/State/Zip: ____________________________________________________________________

Phone Number:  __________ -- __________ -- ___________________    

Email Address: _____________________________

Website Address? ________________________________________________________________

___ I am signing up by myself, so I am paying $10.00.

___ I am signing up with my spouse, so I am paying the couple's fee of $15.00.

___ I want ___ boxed lunch(es) at the Sat. seminar at $6.00 ea.   TOTAL: _______ (Are you doing these, Katherine?)

TOTAL AMOUNT DUE: __________

___Enclosed in the form of a check or money order. (U.S. funds only, please.)

___Please charge to my credit card.   (Info must be provided below.)

~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

Credit Card Information

(*'d items indicate information we must have to process your order)

*Name on card: ___________________________________________________________

*Address of card holder:      __ Same as above        __ Different:

            ______________________________________________________________________

City/State/Zip:  ________________________________________________________________

Phone Number (if different from above):  __________ -- __________ -- ___________________  

Email Address (if different from above):  ___________________________________________  

    (If this is included, you will be sent an e-notification upon processing of your payment.)

*Card Type:     __ MasterCard        __ Visa       __ Discover       __ American Express 

*Card Number:  __________  __________  __________  __________       *Exp. Date:  ____/____

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