Print this form, fill it out, and send to the address below.

October 21-24, 2010

Registration Form

Name:  _________________________________________________________________

Spouse Name:  ___________________________________________________________

Address: ________________________________________________________________

City:  __________________________________________________________________

State:  __________________________________________________________________

Zip:  ___________________________________________________________________

Home Phone (include area code):  ____________________________________________

Work Phone (include area code):  ____________________________________________

E-mail Address:  _________________________________________________________

Name(s) on Nametag:  _____________________________________________________

Church Home:  ___________________________________________________________

Church Address:  _________________________________________________________

Church City:  ____________________________________________________________

Emergency Contact (other than spouse):___________________________________________________

A deposit of $50.00 is needed to confirm your registration.  Please make checks payable to South Plains Church of Christ.

Please mail this form along with your deposit to the following address: