Registration

Form

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I. Demographic Data (Please fill in carefully, all information is important)

His Name

First

Last

Her Name

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Home Phone

His Cell

His Email

Profession

His Birthday

Wedding Anniversary

If Common-law, How many years?

Her Cell

Her Email

Profession

Her Birthday

Name of Child 1

Child 1 - Sex (Male/Female)

Age of Child 1

Child 1 Married/Single

Name of Child 2

Child 2 - Sex (Male/Female)

Age of Child 2

Child 2 Married/Single

Name of Child 3

Child 3 - Sex (Male/Female)

Age of Child 3

Child 3 Married/Single

Name of Child 4

Child 4 - Sex (Male/Female)

Age of Child 4

Child 4 Married/Single

Number of Grandchildren

II. Sponsor Data (Applicable only if you have a sponsor who has invited you or is financially sponsoring you)

His Name

His Phone

Her Name

Her Phone

Email(s)

How do you know your sponsors?

III. Information for the weekend

(Please fill in carefully, all information is important)

a) Wheelchair/Accessibility

b) Food allergy

(Please Specify food allergy for Him)

(Please Specify Food allergy for Her)

c) Comments:

Emergency Contact(s):

Name

Phone

IV. What do you expect from this weekend?

V. Comments or Questions?

Signature His

Clear Signature

Signature Hers

Clear Signature