Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Registration & Housing Options (select one) *

Option One - I am planning to room at the 4-H Center (single occupancy - WITHOUT a roommate). This option includes registration and all four meals at the 4-H Center. Pay $150 online after submitting this form. (Pay earlybird $135 before September 13).

*Option Two - I am planning to room at the 4-H Center (Double Occupancy WITH a roommate). This option includes registration and all four meals at the 4-H Center. Pay $150 online after submitting this form. (Pay earlybird $135 before September 13). *Please list Roommate request below.

Option Three - I am planning on attending the event but have my own lodging (this option includes Lunch and Dinner on Thursday, and Breakfast and Lunch on Friday (Pay $70)

Payment Options *

Payment CANNOT be made at the Retreat Site. All payments MUST be processed through the Regional Office. All Registrations and payments are due to Regional office by October 7th.

I will be making my payment online today

I will be mailing my payment to the Regional Office today