2011 CFC SINGLES and YOUTH FOR FAMILY AND LIFE

USA NATIONAL CONFERENCE

July 29-31, 2011
Irving Convention Center at Las Colinas
500 West Las Colinas Blvd, Irving, TX 75039

REGISTRATION FORM (vs 1.0)

PARTICIPANT INFORMATION
Last Name First Name

Ministry – Encircle One Gender- Circle One Birthday – MM/DD/YYYY Age

CFC SFL / CFC YFL / Coordinator / Other MALE / FEMALE / /
______

HOME INFORMATION
Street Address

City State Zip Code

CONTACT INFORMATION
Home Phone Cell Phone Email Address
( ) - ( ) -

PAYMENT INFORMATION

Payment Schedule Please make checks payable to:

Amount (Occupancy) YFL Registration *** SPECIAL *** CFC – FFL
Total conference fee per person. PROMOTION Please mail or send
Includes bed and meals. forms and payments to:
$195 (quad)
The first 250 Johnny & Fe Poquiz
Amount (Occupancy) SFL Registration participants’ names 2011 CFC SFL Registration
who have fully paid Committee
SFL/YFL registration 1705 Skyline Dr
$195 (quad)
Total conference fee per person. fees received by Garland, TX 75043
$245 (double)
Includes bed and meals. May 1, 2011
$340 (Single) For CFC-FFL Texas
will be included in a Office Use Only:
special raffle during
SFL ROOMMATE REQUEST LIST: the conference. Date Received:
1) Amount Paid:
2) RAFFLE PRIZE: Check #:
A total of 3
3) Notes:
registration fees
4) ($195) will be
*** We will try to accommodate your roommate request, but if we cannot grant it reimbursed.
please take the opportunity to meet other SFL sisters or brothers. ***

SHIRT SIZE AREA INFORMATION

Note: Shirt is not included in Registration fee. To be filled up by Area Conference Coordinator
Encircle One CFC YFL/SFL
S M L XL XXL

To pre-order shirts please include $10 per _______shirt(s)= total $____ Area City State Region
Pre-Order Sales available only until July 1, 2011. After July 1, there will
only be a limited number of T-shirts available for sale. Thank you.

CONFERENCE TEAM INFORMATION

Registration Team Coordinator Host Area Conference Coordinator
Johnny and Fe Poquiz
1705 Skyline Dr
Bembet & Amy Salazar
Garland, TX 75043
(972) 697-7033
(469) 360-5036 (Johnny)
bembet_mesqtx@yahoo.com
(972) 375-8255 (Fe)
jfpoquiz@tx.rr.com
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 Participant Last Name: First Name:

TRAVEL INFORMATION
Transport Type:
Transport Details:
(check one)
___ Air Airport Airline Flight # Date Time
Arrival __ DFW (__DAL)
Departure __ DFW (__DAL)

___ Chartered Bus Name Arrival Date/Time: Departure Date/Time:

___ Car Arrival Date/Time: Departure Date/Time:

Require host area to provide transport from/to airport or station? ____Yes :: _____No
Require host area to provide pre-and/or post-conference housing? ____Yes :: _____No

EMERGENCY INFORMATION
Name to Contact in Case of Emergency Relationship

Home Phone Cell Phone Pager

( ) - ( ) -

Family Doctor Phone / Pager

Hospital Name Address

Medications Currently Being Taken (Please indicate what, how often, any special handling required, etc.)

Medications / Items Allergic To

Physical Activity Restrictions

Special Medical Conditions (Please describe.)

CONSENT & RELEASE WAIVER

I am the undersigned Participant or parent and/or guardian of the child whose name appears below, hereinafter known as “Participant,” and I
hereby give my consent for the Participant to attend the CFC YFL/SFL USA National Conference at the Irving Convention Center at Las
Colinas, Irving, TX 75039.

Couples For Christ Foundations for Family and Life and its Family Ministries (including CFC YFL/SFL), the conference organizers and leaders
and the Irving Convention Center at Las Colinas are, therefore, fully absolved and released from any and all responsibility and/or liability that may
directly or indirectly arise from or be incidental to the Participant’s attendance, participation and involvement in any and all activities within the
scope of the conference. I understand and agree that I hold Couples For Christ Foundations for Family and Life and its Family Ministries
(including CFC YFL/SFL), the conference organizers and leaders and the Irving Convention Center at Las Colinas free and harmless from any
liability, costs or damages to any person/s and/or property caused by, arising out of, or incidental to, the Participant’s attendance, participation
and involvement in this conference.

By signing below, I certify that all the above information is true and correct to the best of my knowledge, and I fully and voluntarily agree to the
above consent and waiver.

__________________________________________________ __________________________________________________
Printed Name and Signature of Participant + Date Printed Name and Signature of Parent/Guardian + Date