Event Registration Form - 63rd Annual Parish Life Conference

Please fax or mail completed form to:
2015 Diocese of Los Angeles Parish Life Conference
St. Andrew Church, Riverside, CA • July 1—5, 2015
Kids Club (Saturday)
Kids Club (Friday)
FEES
Kids Club (Thursday)
Kids Club (Wednesday)
Antiochian Women Brunch (Friday)
Parents must be attending Order Dinner
Order of St. Ignatius Children’s Dinner (Thursday)
Order of St. Ignatius Dinner (Thursday)
Clergy/Clergy Wives Lunch (Wednesday)
Clergy & Clergy Wives Only
(Includes Transportation & Dinner at Church)
St. Andrew Church Excursion (Wednesday)
Teen Dance (Friday)
Ice Cream/Sorbet Social (Friday)
Hospitality Night Dinner (Thursday)
Regular Ticket Book
Early Bird Ticket Book
Teen SOYO
Antiochian Women
Order of St. Ignatius
Clergy/Clergy Wife
Adult
Teen (13-19)
Female
PLEASE PRINT CLEARLY.
Male
Place an X in the appropriate boxes for
each listed person.
Child (12 & under)
Anyone under the age of 18 MUST submit completed and signed Parent Consent Form and Teen Code of Conduct
(Teens only) in order to
receive their Badge.
Fellowship of St. John
Please write your name as you would
like it to appear on your badge.
ADDITIONAL EVENTS
Mandatory Registration Fee
(Ages 12 & older)
INDIVIDUAL EVENTS
$(Included in Ticket Book)
Awards Brunch (Sunday)
TICKET BOOK
4th of July Dinner/Show/Dance (Saturday)
Early Bird Deadline:
May 1, 2015
Processing Fee: (Required for all 12+ who do not purchase event tickets)
Register On-line: www.laplc.org
Saturday Night Show/Dance only
Registration Form
2015 Diocese of Los Angeles PLC
St. Andrew Church
4700 Canyon Crest Dr. Riverside, CA 92507
Phone: 951-369-0309 • Fax: 949-613-8340
www.laplc.org • laplc2015@gmail.com
Total
1
$
2
$
3
$
4
$
5
$
6
$
Parish Name: __________________________________
Parish City:
___________________
State: ________
Diocese:
___________________________________
Children (Ages 4-12)
$120 $140
$50 $35
$50 $45
$25
$90
Teens (Ages 13-19)
$160 $180
$55 $40 $20 $85 $50
$25
$90
$45 $50
$20
$10
$
Adults/Clergy
$160 $180
$55 $40
$85 $50
$25
$90
$45 $50
$20
$10
$
$50
$0
$45 $35 $15 $15 $15 $15
___________________________________ Phone: ____________________________  AMEX
 VISA
 MasterCard
 Check
Address:
___________________________________ Email: ____________________________ Credit Card # _______________________________
Date: ____________________________
City:
___________________________________
Exp. Date ____________ CVV2 ___________
State: _______ ZIp Code: ____________
Amount ____________
I acknowledge and understand that all Charges and/or Donations are non-refundable.
Refer to policy statement: www.antiochianevents.org/privacy/109.
Signature _______________________________
Name:
Unsigned forms will not be processed!
$
We encourage everyone to pre-register. Some events
may sell out and will not be available at the Conference.
Make check payable to: St. Andrew PLC and mail to
above address. Fax credit card payment to number
above. For all credit card payments the name and
address on this form must match the name and
address on the credit card billing statement.