R E G I S T R A T I O N - F O R M
Please PRINT and then fill out this form and return with deposit
DEADLINE: May 1, 2012
FINAL DEADLINE: May 30, 2012 includes $50 late fee.
Mail to: Jane Woodhouse, GMC, PO Box 29, Peacham, VT 05862.
_________________________________________________________
Name
_________________________________________________________
Address
_________________________________________________________
City, State, ZIP Country
___________________________________________
Phone
_________________________________________________________
Email
Register me for the 37th Annual Conference on the Great Mother and the New Father.
June 2 - Sunday, June 10, 2012 at Camp Kieve, Nobleboro, Maine
Conference fee: $910 (includes lodging and meals).
We offer a $35 discount if paid by cash/check.
Payment Options:
____ Charge my credit card $910 (Charge credit card $960 if registering after May 1.).
____ Check for $875 is enclosed ($35 cash discount). Check for $925 after May 1.
____ Check for $100 cash deposit enclosed.enclosed. I will send a check for $775 by
May 1. I will send a check for enclosed. I will send a check for $775 by
May 1. I will send a check for $825 after May 1. after May 1..
Please make checks payable to:
Conference on the Great Mother & New Father
Full refunds on deposit are only available until April 1.
Full balance due by May 1, 2012.
I would like to make a contribution to the diversity/work/scholarship fund:
____$100 _____$50 _____$25 ____other
I am applying for Financial Assistance:
____ Work/Study
Cost: $535 by credit card or $500 by check.
After May 1: $585 by credit card or $550 by check
(For more details and an application go to Financial Assistance under the Attend
menu. Application and Deposit deadline is April 1st )
____ Scholarships
(For more details and an application go to Financial Assistance under the Attend
menu. Application and Deposit deadline is April 1st )
I would like to register my children in the Children?s Program.
The program is designed for children from age 5 to 15.
____ Families: # of children (ages 3 to 18)* ____ x $500 (credit card) each = $_______
OR ____ x $475 (check) each = $________
Please list children’s ages: _______________________________________
* Must be in high school and accompanied by parent.
____ I have a medical condition that requires special arrangements.
_________________________________________ (Please describe.)
____ This is my first time attending the Conference.
Please tell us how you heard about the conference. Thank you.
__________________________________________________________________________
If using credit card, please fill out the following:
___________________________________________
signature
___________________________________________
Print your name
Type of card: ____ Mastercard ______ VISA ______ CVV2 code on back_____
________________________________________expiration date______
Account Number
TOTAL CHARGE: $_______________________
