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Proctor Registration 2014

 

Personal Information

*1. Title (as it should appear on the name badge)
(Select one of the available choices or enter a different value.)



2. Please provide us with the following information about yourself:

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Name:

 

 

 

 

     

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City/State/ZIP:

 

    

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What's this?

3.  


 

Church/Organization Information

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10.
Question - Not Required - Send all correspondence to my:


11. Do you have an special dietary restrictions? (If other, please explain)
(Select one of the available choices or enter a different value.)



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13.

(Maximum response 255 chars, approx. 5 rows of text)

 

Registration & Payment Information

*14.
Question - Required - Participation:


15.
Question - Not Required - Registration:

16.
Question - Not Required - Optional airport shuttle service (round-trip):

17.
Question - Not Required - Individual day registration ($100 for each day you attend):

18.
Question - Not Required - Individual day registration ($65 for each day you attend):

19.
Question - Not Required - CDF Freedom Schools® Program for Children ages 5-15 (three-day registration):

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   Please leave this field empty

     

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