Registrant Name *

First Name

Last Name

Phone *

(###)

###

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Registrant will be attending as...

Delegate

Clergy

Attendee/Guest (Non-Voting)

Name of Parent or Guardian

First Name

Last Name

Parent or Guardian Phone

(###)

###

####

If yes, please check all that apply.

Vegetarian

Gluten Free

Vegan

Dairy Intolerant

Other (please indicate below)

Where will you be staying during the gathering? *

Commute Locally

At the Wild Horse

Name

First Name

Last Name

Phone

(###)

###

####

I/my delegation will be bringing one or more prayer quilts/shawls to give as a blessing.

One quilt or shawl

Two quilts or shawls

I will be making my donation by... *

Credit Card

Check