Clergy Consultation Registration Form

FEBRUARY 7-9, 2011 – ANTIOCHIAN VILLAGE CONFERENCE CENTER – LIGONIER, PA

REGISTRATION INFO
Name Address

Phone Email

Roommate #1 Roommate #2

Roommate #3 Roommate #4

Spouse Name (if applicable)

PACKAGE PRICE (includes two night lodging/meals):

one

Single $245.00/person $
Double $180.00/person $
Triple $160.00/person $
Quad $150.00/person $
Total Due: $

NIGHTLY RATES (includes meals):
one

Single M T (circle as appropriate) $140.00/person $

Double M T (circle as appropriate) $105.00/person $
Triple M T (circle as appropriate) $95.00/person $
Quad M T (circle as appropriate) $90.00/person $
Total Due: $

COMMUTER RATES (includes meals):
one

Breakfast T W (circle as appropriate) $16.00/person/day $

Lunch T W (circle as appropriate) $25.00/person/day $
Dinner M T (circle as appropriate) $25.00/person/day $
Total Due: $

Select payment type (please check one):

credit card check $__________ cash $___________
(Amount enclosed) (Amount enclosed)

If paying by credit card:

Cardholder’s name: _______________________________________________________________
Card type: Visa MasterCard Card No:____________________Exp date: ____________

Please return registration form with your remittance by January 31 to:

Christian Church in PA
PO Box 90
Greensburg, PA 15601

Any questions, please don’t hesitate to contact Christine at 724-834-5023 or email at cjohns@padisciples.org.