[PDF]Registration! -

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KIRBY WOODS BAPTIST CHURCH 12TH ANNUAL MID-SOUTH DEAF WOMEN’S RETREAT APRIL 28-30, 2017 Registration (PLEASE PRINT) Name_____________________________________________________ Address___________________________________________________ City__________________________ State_________ Zip Code______ Age Group (Circle): Daytime Phone________________ VP:_____________________ 26-45 Emergency Contact_________________________________________ 12-25 Church Name__________________________________________ 46-65 66- up Medical Information__________________________________________ Due to physical limitations- I need a room on the first floor__________________________ (Subject to availability) Please check your choice of a room: Early Bird Special before January 31, 2017 _____1 person at a cost of $215 _____2 person at a cost of $140 _____3 person at a cost of $120 _____4 person at a cost of $110

From February 1 to March 1, 2017 _____1 person at a cost of $230 _____2 person at a cost of $155 _____3 person at a cost of $135 _____4 person at a cost of $125

Price includes, Lodging, Meals, and T-shirt Ask your local church for financial assistance/ scholarship before January 31, 2017 Non-refundable after March 1, 2017 I have talked to the following women and we plan to share a room: 1. You 2. _______________________________________ 3. _______________________________________ 4. _______________________________________ ***IF YOU DO NOT PUT ANY NAMES, YOU WILL BE RANDOMLY ASSIGNED WITH OTHER WOMEN, BASED ON YOUR PAYMENT.***

RIDE KWBC BUS (CIRCLE): Yes No T-SHIRT (CIRCLE): SMALL MEDIUM LARGE Mail Completed Registration Form and Payment to: Kirby Woods Baptist Church c/0 Deaf Ministry 6325 Poplar Avenue Memphis, TN 38119




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