Conference Registration Form
(Step 1 of 2)

*First Name:	*Last Name:
Title:	Organization:
Work Address:
City:	State:
Zip:
Home Address:
City:	State:
Zip:
Email:
*Primary Phone:
Secondary Phone:
Emergency Contact in Abilene during the conference:
Name:	Phone:
CenterPeace News:
I would like to receive the CenterPeace Newsletter in my email
Yes
No
I would like to receive mail from CenterPeace at:
My home address
My work address
Do not send me mail
Please Choose all that apply:
High School Student
Undergraduate Student
Graduate Student
Elder
Counselor
Pulpit Minister
Youth Minister
Campus Minister
Other area of ministry
Other
Cost Options: (To be paid in Step 2)
Individual: $100
Student: $20
Family (2 or more family members): $175
Comments/Feedback/Suggestions: