ON-LINE Registration Form

First & Last Name:
Address:
City/State/Zip:
Email Address:
Phone Number:
Roommate:
Roommate:
Roommate:
Credit Card #:
Security Code:
Expiration Date:
Billing Zip Code:
Registration Price:	Pre-Sale ($50) Retreat Package for 2 ($150) 3rd or 4th Person ($50)
Retreat T-Shirt ($15):	Yes No
T Shirt Size:	S M L XL N/A
Would you like to carpool?:	Yes No
How did you hear about the retreat?:	RMC Ministries Website Dallas Black Local Restaurant NewspaperMagazine RadioTelevision By Mail FriendRelative
Registration Total:         (Calculate the above items.  This amount will be charged to your credit card.)
Please complete (1) form per person.