REGISTRATION FORM
Please list each name as you wish them printed on name tags.
List all additional persons registering on form;
NAME ______________________________________________ (Please specify , "Y" for High School and "C"for Child)
ADDRESS___________________________________________ 1_________________________________________________
CITY _______________________STATE__________________ 2_________________________________________________
ZIP_________________PHONE________________________
E-Mail_____________________________________________
CONFERENCE REGISTRATION FEES
ONLY:
(your canceled check will be your receipt)Cash_____
Check_____Credit
Card_____Date____________
Adult 3 days
$79
until
6/15
$89
at
the
Door------------------------$__________
Married Couple 3 days
$150
until 6/15 $169 at the
Door----------------------$__________
Youth & Children:
$25 until 6/15
$30 at the Door---------------------$__________
Family 3 days (2 adults, 2
children under 18 Free $180 until 6/15
$199 at the door$__________
One Day: Friday $50 ( ) ; Saturday $ 59 (
); Sunday $50 ( ) until 6/15
- $__________
SPECIAL DISCOUNTED PACKAGE
CROWNE
PLAZA HOTEL OF FOSTER CITY
3 DAYS CONFERENCE REGISTRATION
FEES, PLUS HOTEL 3 DAYS / 2
NIGHTS
Adult: (double occupancy):
$195
- until 6/15 $__________
Adult (Single
occupancy):
$285
- until 6/15 $__________
Married
Couple:
$320-- until 6/15
$__________
Family:
$350
-- until 6/15 $__________
Donation to help others attend---------------------------------------------------------------------$__________
Total Paid (Make checks payable to Saint
Raphael
Ministries)---------------------------$__________
I will pray one Rosary or other prayer daily for the
success of the Conference ----------------- ( )
CHARGE: VISA MC DISCOVER AMEX Card
No._____________________________________
Exp. Date______________________Signature
_______________________________________
You can FAX credit card registration to (510)
897-6625
or E-Mail: srm.inc@juno.com
For more information call 1(800)456-4197
Secured
online
Registration