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Winter Retreat Registration and Payment

Winter Retreat 2012 Registration:

1.
*

Name:

2.
*

Gender:

(1 required)
Male   Female
3.
*

Street:

4.
*

City:

5.
*

State:

6.
*

Zip:

7.

Would you like more information about available scholarships?

Yes   No
8.
*

Expected High School Graduation Year:

9.
*

School Name:

10.

Please enter the name of school you attend if it was not on the list above.

11.
*

Month of Birth:

12.
*

Day of Birth:

13.
*

Year of Birth:

14.
*

Parent or Guardian First & Last Name(s):

15.
*

Primary Phone Number:

16.

Cell or Alternate Student Phone Number:

17.

Parent or Guardian Alternate Phone Number:

18.
*

Do you own a Campus Way Bible?

19.
*

Adult Shirt Size:

20.

Who referred you to this event? Or how did you find out about it?

* Enter Your Email Address:

Type in the text that you see above:

  

 

 

 

* Please select winter retreat payment menu

Campus Way
308 E. Oak Crest Dr.
Wales, WI 53183
Phone: 262-968-2988

jay@campusway.org

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