Invigorate Church

Personal Info
Name * First Last
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone * ### - ### - ####
Email *
Church Info
Church Name *
Church Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Registration Options
(please check only one)
	Student Registration	18+ (Adult) Registration
Early Bird ( now - July. 31st '10) 18+ - $55 / Student - $40	1	2
Full Registration ( Aug. 15th - Aug. 13th '10) 18+ - $75 / Student $55	1	2

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