Pure Rebellion-Family with 4 Registrants

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Pure Rebellion Family with 4 Registrations

The registration form below is intended for use by families with four registrants and can be used for either two parents and two students, or one parent and three students. This registration will provide a $5 discount off the $40 individual registration costs (four registrants X $10). Once you enter the information into the pertinent fields, click on Submit at the bottom of the form.

You will be forwarded to the payment screen where you will renter the Parent Name (for payment reference), and click on Buy Now. You will then be forwarded to the PayPal screen for online payment for registration. PayPal is a secure site for online payment.

Registration for your students and adultts is not valid or complete until payment is made.

If this is not the type of registration you want, click RETURN to go back to the previous page.

Registration for your students and adultts is not valid or complete until payment is made.

If this is not the type of registration you want, click RETURN to go back to the previous page.

Pure Rebellion Family with 4 Registrations


Parent (1)

First Name*
Last Name*
Address*
City,State,Zip*
Primary Phone #*
Email Address
Church
Church City Location
Parent (2)

First Name*
Last Name*
Student (1)

First Name*
Last Name*
Age (as of 3/25/12)*
Male/Female*	Male Female
School Grade*
School*
Student (2)

First Name*
Last Name*
Age (as of 3/25/12)*
Male/Female*	Male Female
School Grade*
School*
Student (3)

First Name
Last Name
Age (as of 3/25/12)
Male/Female	Male Female
School Grade
School

Submit