Mission Action Registration

2014 MISSION ACTION DAY REGISTRATION FORM

Online Registration Deadline is March 10, 2014 at 5:00 PM

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Please select phone type: *

Email *

Please Select A District *

Local Church/Unit *

Please Select Gender *

Please Choose Which Category Fits You Best: *

Please Only Check Those That Apply: *

Child Care Needed Special Needs/Diet

If you put a check in one of the boxes above, please include number and ages of children and/or explain special needs/diet: *

NOTE: If you are bringing children, please bring a sack lunch for each child or register them separately and pay $12.00 for each child.

Please select Form of Payment: *

All fields with a red asterick (*) are required fields and must be filled in.

Registration $12.00 per person, includes lunch.
Please make checks payable to: WI Conference UMW.
Registrar: Shirley Carpenter, 2711 North Biron Drive, Wisconsin Rapids, WI 53140
NOTE: If you register for this event, please be sure to pay your registration and show up to the event.
We need an accurate head count for lunch. Registrations are transferrable, not refundable.