United Methodist Missionary Association Registration Form
Mission Forum and Gathering 2007

Name of Delegate
Address
City
State/Province
Zip or Postal Code
E-mail
 
Emergency Contact
Home Phone
Work Phone
 
Health Insurance Carrier
Plan Number
Policy Number
 
Affiliation (Check all that apply): [ ] NADAM
[ ] NCVIM
[ ] UMMA
[ ] India Reunion
[ ] SE Asia Reunion
[ ] Philippines Reunion
[ ] Other (please name) ________________________
Housing: [ ] Hotel - I will reserve and pay for my own hotel room.
[ ] Loder Hall Dormitory (Room total = $186)
(Roommate's name: _____________________________ )
Item Loder Hall Hotel
Registration per person: Non-refundable 35. 35.
Food per person* 105. 105.
Dormitory (Total for 1 or 2 participants per room)* 186. _____
Total 326. 140.

*Refundable until May 1, 2007


Payment

Make check payable to: Trinity UMC with $326 for Loder Hall option, or $140 if you reserve and pay for your own hotel room.

Please Mail This Form To:
Richard Vreeland, 182 Ameren Way - Apt. 752, Ballwin, MO 63021-3317, USA
Information on registration: Tel: 636.825.6351; email: