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CM MN Registration Form

CM MN Registration Form

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Published by magoo65293

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Published by: magoo65293 on Feb 07, 2014
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CM Minnesota - A Tale of Two Cities!

Friday 8/29/14 - Monday 9/1/14
Registration Form
Please e-mail completed form to CMMinnesota@gmail.com
E-mail (please PRINT clearly):__________________________________________________________________
Please find me a Roomie! # of Roommates requested: 1___________ 2___________ 3___________
(2 in room = $76.89 ea/night; 3 in room = $51.26 ea/night; 4 in room = $38.44 ea/night)
Emergency and Medical Information
(Medical info optional but strongly encouraged)
Emergency contact Name:_____________________________________________Relationship:____________
Doctor's name:________________________________________________Phone:_(______)_________________
Doctor's address:______________________________________________________________________________
Medical insurance carrier:____________________________________________ID#______________________
Blood type:________________________________________________________________
ANY Medical Information you think I would need to know about in an
emergency (allergies, bad knees, medications, etc.):
Food Information
Snacks & bottled water will be available in the Hospitality Suite throughout
CM MN. Please let us know any special preferences or needs below:
Special Diet
Events Fee $270
Payment Plan: 4 payments of $67.50 due 3/15/14, 4/15/14, 5/15/14, with full & final payment
due 6/15/14.
Preferable: Send $ electronically. most banks these days have ways to easily transfer $ or do
e-checks for free. Citibank has "PopMoney", for example, where you only need a person's e-mail
to send $. Use of PayPal is discouraged as they support Planned Parenthood.
Also Fine: Checks by SnailMail to Margot Hird, P.O. Box 14236, Saint Paul, MN 55114.
Email CMMinnesota@gmail.com for questions or call Margot @ (818) 648-7740.

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