Youth Registration Form
Youth conference
attendees must be from ages 12-19.
0 Yes! Insha’Allah, I plan to attend
0No. I can’t attend, but please accept the enclosed donation, fisibilillah.
PLEASE PRINT CLEARLY !
Name:______________________________
Address:_____________________________
City:_____________ State:____
Zip:________
Phones: (H)___________
(C)_____________
Email address:_________________________
0 Jr. Conference Birthdate ________________
( Required )
Lunch:
0Herb Seared Chicken Breast
Tilapia with Tomato Chutney
0Vegetable Lasagna
Dinner:
Herb and Oil Infused Chicken Breast
Baked Salmon
Vegetarian
Mediterranean Purse on Lentil Chili
Method of Payment
0Enclosed is my full payment of 0$90* 0$100 0$125
*Early
Bird Special $90 price must be paid in full by
October 31.
0Please set up a monthly payment plan
0Enclosed is my initial deposit of $40
0check
0money order
1st payment of $40 due by Jan. 28, 2014
2nd payment of $30
due by Feb. 28, 2014
3rd payment of $30
due by Mar. 28, 2014
Today’s
date:_____________________________
Make all checks or money orders payable to: WCMAS
and mail it to: 1335
W. North Avenue
Baltimore,
MD 21217
