PLEASE COMPLETE this form AND MAIL your check to the address listed

below.  Thanks.

Upon completing this form press the “submit” button at the bottom.  After clicking “Submit” a confirmation page will appear on your screen.  If this confirmation page does not appear your registration will not be received!  If this occurs please contact our office at (724) 463 8422

VISITOR Registration Form

2010 ELCMA Annual Appalachian Assembly

April 26, 27, 28, 2010

Riverside Inn, Cambridge Springs, PA

Name

 

Address         City        State      Zip

Phone  

E-mail 

VISITOR representing (Synod, ELCMA Council)  ELCMA Council       

ELCA Churchwide Unit    Other Agency

Bringing another Visitor?  Please have them fill out a separate Visitor Form.

Child Care required?  Select Yes NO    Names and ages of children

  List all names and ages here

Note that child care is provided for the business sessions only.  A monetary gift is requested for the caregivers.

Do you have any dietary concerns we can attempt to address?

  List all dietary concerns and allergies here

Commuter (no lodging required, only meals)  Monday     Tuesday     Wednesday

                 Meals:  (commuters ONLY) select meals you will be present for.

                                  Monday dinner $22

                                  Tuesday Breakfast $10

                                  Tuesday Lunch $12

                                  Tuesday Dinner $10

                                  Wednesday Breakfast $10

Arriving by PLANE?

Give us this data and we will coordinate a ride from the Pittsburgh Airport.  Arrivals must be prior to 10 AM Monday.  Departures cannot be prior to 4 PM Wednesday

Monday Arrival Flight # Time

Wednesday Departure Flight # Time

Do you need picked up at the Pittsburgh, PA Airport?  select yes no

Cell number (to assist in connecting with ride)

Room Information

>>>>>NOTE: Single accommodations are in limited supply.  Register early to insure availability. 

                 Pricing includes  rooms for Monday night  and Tuesday night  and  meals for MondayDinner

                 Tuesday Breakfast, Tuesday lunch, Tuesday Dinner, Wednesday Breakfast

**FYI 2 rooms share one Bathroom**

Single room $  230.00  OR  double room $147.00

           If double room is selected do you have a roommate ? Yes No Select

           If ‘no’, a roommate of the same gender will be paired with you.

           If yes, please provide the name of your roommate      

**Roommate must name you on their form as well **                                                                

 Field trips - no charge                                                                                       

TOTAL  please total your cost and enter amount of check being sent       

I am covering the costs for a second visitor and paying with one check.  Name of second visitor :

My costs are being covered by someone else.  Name of  person covering costs:

>NOTE : an additional late fee of $50.00 will be Required for any registration forms received after March 1st 2010!<<

Any other Concerns or questions please list them here:

 

>>>>>>We will be making reservations for you from this sheet. <<<<<<

Please submit all checks  no later than March 01, 2010 to:

ELCMA, PO Box 338, Indiana, PA 15701-0338 or Phone/Fax: 724/463-8422, admin@elcma.org

Upon submitting this form a confirmation page should appear on your screen… if you do not see this confirmation your registration was not received! Please call our office.

NOTE:  Further correspondences regarding assembly registration and materials will be sent via

e-mail (in a cost-savings effort) unless you designate otherwise.  Please check your e-mail for confirmation of the receipt of this registration form and again when the check  arrives at our office.  You may at anytime go to our website and access all of the necessary materials for the Assembly as they become available.    Thank You!

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