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Missionary Diocese of the Central States - Synod Registration
Please complete all blocks.
Thank you for using this on-line registration form.
When you complete this form and press the Send Now button (at the bottom of the form) the form will be sent to our Synod Registrar, Deacon Dave Abshear. No sensitive information is collected with this form.

Notes: Up to six registrations may be submitted on a single form. When you have filled in all of the information for your attendees, scroll to the bottom and send the form. If you have more than six attendees to register, you may submit aditional forms. All registrants do not need to be on one form. If you are registring yourself, you still need to complete the submitter information at the top. A partially completed form cannot be saved for later use. For techical support, call Andy at 937-409-8674. 


(REQUIRED) Form Submitters Name	, Email ,
Phone Number			, Congregation	

PERSON(S) BEING REGISTERED:

#1
Title: 			
First Name:		
Middle Name/Initial: 	
Last Name:		
Suffix (Jr, III):	
Known As for name tag:	
Status:			 (complete if "Other" selected)
Affiliation(if not REC):
Home Mailing Address:	
Email Address:		
Home Phone:		
Cell Phone:		
Estimated Arrival:	
Mode of Transportation:	
Attending Banquet?	YES or NO (Yes, even volunteers have to pay for their banquet.)
Any special food requirements or other needs?


#2
Title: 			
First Name:		
Middle Name/Initial: 	
Last Name:		
Suffix (Jr, III):	
Known As for name tag:	
Status:			 (complete if "Other" selected)
Affiliation(if not REC):
Home Mailing Address:	
Email Address:		
Home Phone:		
Cell Phone:		
Estimated Arrival:	
Mode of Transportation:	
Attending Banquet?	YES or NO (Yes, even volunteers have to pay for their banquet.)
Any special food requirements or other needs?


#3
Title: 			
First Name:		
Middle Name/Initial: 	
Last Name:		
Suffix (Jr, III):	
Known As for name tag:	
Status:			 (complete if "Other" selected)
Affiliation(if not REC):
Home Mailing Address:	
Email Address:		
Home Phone:		
Cell Phone:		
Estimated Arrival:	
Mode of Transportation:	
Attending Banquet?	YES or NO (Yes, even volunteers have to pay for their banquet.)
Any special food requirements or other needs?


#4
Title: 			
First Name:		
Middle Name/Initial: 	
Last Name:		
Suffix (Jr, III):	
Known As for name tag:	
Status:			 (complete if "Other" selected)
Affiliation(if not REC):
Home Mailing Address:	
Email Address:		
Home Phone:		
Cell Phone:		
Estimated Arrival:	
Mode of Transportation:	
Attending Banquet?	YES or NO (Yes, even volunteers have to pay for their banquet.)
Any special food requirements or other needs?


#5
Title: 			
First Name:		
Middle Name/Initial: 	
Last Name:		
Suffix (Jr, III):	
Known As for name tag:	
Status:			 (complete if "Other" selected)
Affiliation(if not REC):
Home Mailing Address:	
Email Address:		
Home Phone:		
Cell Phone:		
Estimated Arrival:	
Mode of Transportation:	
Attending Banquet?	YES or NO (Yes, even volunteers have to pay for their banquet.)
Any special food requirements or other needs?


#6
Title: 			
First Name:		
Middle Name/Initial: 	
Last Name:		
Suffix (Jr, III):	
Known As for name tag:	
Status:			 (complete if "Other" selected)
Affiliation(if not REC):
Home Mailing Address:	
Email Address:		
Home Phone:		
Cell Phone:		
Estimated Arrival:	
Mode of Transportation:	
Attending Banquet?	YES or NO (Yes, even volunteers have to pay for their banquet.)
Any special food requirements or other needs?

SEND NOW?
To clear form of all typing and start over, press the RESET button.  

THANK YOU!

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