Attendee Registration Form

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Attendee Registration Form

Abstinence Clearinghouse Conference

July 22-25, 2008, Rosen Shingle Creek, Orlando, FL

9939 Universal Blvd., Orlando, FL 32819

Please complete 1 form for each attendee & Fax to 605.335.0629

Registration: Hotel reservations are separate; please call 866-996-6338 and ask for the “Abstinence Clearinghouse” special conference rate. Sponsors should call 605.335.3643 before filling out this form. No refunds will be given for registration or meal packages.

The following includes meal packages:

Affiliate: $199 Non-affiliate: $299 International: $125

The following do not include meal packages:

Teen: FREE

Meal Package (includes Wednesday lunch and Friday dinner): $125

Total Registration Amount $ ____ __

____________________________________ ____________________________________
First Name Last Name

____________________________________ ____________________________________

Organization Affiliate ID and Level – for Affiliate Registration

______________________________________________________________________________

Address

________________________________________________________ ______________

City, State, Zip Country

_____________________________________ ____________________________________

Phone Fax

______________________________________ ____________________________________

E-mail Web Site

Payment Information * The Abstinence Clearinghouse reserves the right to reject any registration for any reason.

Check # _________

Credit Card (circle one) VI MC DS (Sorry no AMX) Total Amount (Registrant) $ _____________

_________________________________ __________ ________ ______________________________________

Card Number V-Code Exp. Date Name on Card

Office Use Only

Payment Processed on:__________ by: _________ RE: ______________ Package Sent: __________ by: _______