Embers to a Flame Conference Registration Form

*When you complete this form you'll be redirected to the payment page. Registration is not complete until payment is received. 

 

Name:
Position in Church:
Church Name:
Church Address:
Church City:
Church State:
Church Zip:
Church Phone:
Cell Phone:
Church E-mail:
If you are a Key Leader, please also include your home address and e-mail.
Home Address:
Home City:
Home State:
Home Zip:
Home Phone:
E-mail:
Please choose which conference is desired:
October 1-2, 2010 (Boston, MA)  - $50
January 21-23, 2011 (Birmingham, AL)  - $175
$25 deposit due at registration. No refund for cancellations received less than two weeks
prior to conference.  Registrations can be transferred to another attendee for the same
conference.
Denomination Affiliation:
Please print this page for your records.