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
$75
until
5/29
$79 until 6/20 $89
at
the
Door------------------------$__________
Married Couple 3 days $105 until 5/29
$120
until
6/20 $135 at the
Door----------------------$__________
Youth & Children: $20 until
5/29 $25 until
6/20
$30 at the Door---------------------$__________
Young Adults - Saturday $35 until
6/20
$45 at the
door---------------------$__________
Family 3 days (2 adults, 2
children under 18 Free $140 until 5/29 $150 until
6/20 $180 at the door$__________
One Day: Friday $35 ( ) , Saturday $ 49 (
) Sunday $35 ( ) until 6/20 -
$55 Per day at the door- $__________
SPECIAL DISCOUNTED PACKAGE
CROWNE
PLAZA HOTEL OF FOSTER CITY
3 DAYS CONFERENCE REGISTRATION
FEES, PLUS HOTEL 3 DAYS / 2 NIGHTS
Adult: (double occupancy): $175
PER
PERSON
until 6/20
Later
$195
-$__________
Adult (Single
occupancy):
$275 until 6/20
Later
$285
-$__________
Married
Couple:
$295 until 6/20
Later
$315--$__________
Family:
$310 until 6/20
Later
$325
--$__________
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)
897-6725
or E-Mail: srm.inc@juno.com
For more information call 1(800)456-4197
Secured
online Registration