Registration Form

Central Ohio Reformation Institute, October 28-30, 2008

(To be completed & mailed to DCB Communications, P.O. Box 1387, Mount Vernon, OH 43050)

Name_____________________________________ E-mail address_______________________

Physical Address________________________________________________________________

Home phone number__________________ Cell phone number____________________

Mailing address (if different from above):

______________________________________________________________________________

Church Name__________________________________________________

Church address_________________________________________________________________

Position held (Check one): Pastor___ Elder___ Evangelist___ Other___

Person to be contacted in event of emergency:

Name______________________________________ Relation___________________

Address_______________________________________________________________________

Phone number(s)______________________________________________________________

Special dietary considerations:

Special health issues:

Amount enclosed includes: Registration Fee of $50.00 ____     Lodging for 2 nights: (2 X $55=$110.00)____ If sharing room ( 2 X $27.50=$55.00)____   6 Meals: $56.00____

Total enclosed ($216.00)____ (Total=$161.00 if sharing room)____            Indicate (X) here if check for lodging and meals will be sent later (Deadline: October 1st)____

                              Note: All checks should be payable to "DCB Communications."