Please fax or mail completed form to: 2015 Diocese of Los Angeles Parish Life Conference St. Andrew Church, Riverside, CA • July 1—5, 2015 Kids Club (Saturday) Kids Club (Friday) FEES Kids Club (Thursday) Kids Club (Wednesday) Antiochian Women Brunch (Friday) Parents must be attending Order Dinner Order of St. Ignatius Children’s Dinner (Thursday) Order of St. Ignatius Dinner (Thursday) Clergy/Clergy Wives Lunch (Wednesday) Clergy & Clergy Wives Only (Includes Transportation & Dinner at Church) St. Andrew Church Excursion (Wednesday) Teen Dance (Friday) Ice Cream/Sorbet Social (Friday) Hospitality Night Dinner (Thursday) Regular Ticket Book Early Bird Ticket Book Teen SOYO Antiochian Women Order of St. Ignatius Clergy/Clergy Wife Adult Teen (13-19) Female PLEASE PRINT CLEARLY. Male Place an X in the appropriate boxes for each listed person. Child (12 & under) Anyone under the age of 18 MUST submit completed and signed Parent Consent Form and Teen Code of Conduct (Teens only) in order to receive their Badge. Fellowship of St. John Please write your name as you would like it to appear on your badge. ADDITIONAL EVENTS Mandatory Registration Fee (Ages 12 & older) INDIVIDUAL EVENTS $(Included in Ticket Book) Awards Brunch (Sunday) TICKET BOOK 4th of July Dinner/Show/Dance (Saturday) Early Bird Deadline: May 1, 2015 Processing Fee: (Required for all 12+ who do not purchase event tickets) Register On-line: www.laplc.org Saturday Night Show/Dance only Registration Form 2015 Diocese of Los Angeles PLC St. Andrew Church 4700 Canyon Crest Dr. Riverside, CA 92507 Phone: 951-369-0309 • Fax: 949-613-8340 www.laplc.org • [email protected] Total 1 $ 2 $ 3 $ 4 $ 5 $ 6 $ Parish Name: __________________________________ Parish City: ___________________ State: ________ Diocese: ___________________________________ Children (Ages 4-12) $120 $140 $50 $35 $50 $45 $25 $90 Teens (Ages 13-19) $160 $180 $55 $40 $20 $85 $50 $25 $90 $45 $50 $20 $10 $ Adults/Clergy $160 $180 $55 $40 $85 $50 $25 $90 $45 $50 $20 $10 $ $50 $0 $45 $35 $15 $15 $15 $15 ___________________________________ Phone: ____________________________ AMEX VISA MasterCard Check Address: ___________________________________ Email: ____________________________ Credit Card # _______________________________ Date: ____________________________ City: ___________________________________ Exp. Date ____________ CVV2 ___________ State: _______ ZIp Code: ____________ Amount ____________ I acknowledge and understand that all Charges and/or Donations are non-refundable. Refer to policy statement: www.antiochianevents.org/privacy/109. Signature _______________________________ Name: Unsigned forms will not be processed! $ We encourage everyone to pre-register. Some events may sell out and will not be available at the Conference. Make check payable to: St. Andrew PLC and mail to above address. Fax credit card payment to number above. For all credit card payments the name and address on this form must match the name and address on the credit card billing statement.
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