Registration Form

For Barb Shelton's San Jose, Calif. Conference

August 13~14, 2004

DIRECTIONS for REGISTERING:

1)  Click to "Full Screen" and then print out this form.

2)  Fill in this form by hand. (Yes, the old fashioned way! Weird, huh?!?)

(Do NOT try to type it in here;   I don't have it set up to work that way.)

3)  EITHER:

A - Write out a check or money order for the

correct amount, payable to Barb Shelton, or...

B - Write your credit card info at the bottom

of this form.

4)  Mail the completed form (with payment if

paying by check or money order) to:

Name of Mom: ____________________________________________________________

My  [ husband / teen ]    [ __will   __will not ]  be attending with me on  Friday night.

My  [ husband / teen ]    [ __will   __will not ]  be attending with me on  Saturday.

       (Neither husbands nor teens have to pay, but we do need to know how many to set up for! )

___ I have read  Barb's Policy on children at her meetings  and, whether I agree or not (and it's OK if I don't), I will comply.    (nicely  ;-) )

Address: ________________________________________________________________________

City/State/Zip: ____________________________________________________________________

Phone Number:  __________ -- __________ -- ___________________    

Email Address: _____________________________

Website Address? ________________________________________________________________

___ I am signing up July 4 or after, so I am paying the regular fee of $40.00, and understand I will NOT receive a free tape (much as I would have liked to have had one and wish I'd signed up earlier! )

___ I am signing up before the Early Bird deadline of July 3, so I am paying $30.00 and understand that I will receive (at the conference) a free tape from Barb.

TOTAL AMOUNT DUE: __________

(Payment must be enclosed.)

___Enclosed is a check or money order.  (U.S. funds only, please.)

___Please charge to my credit card.   (Info must be provided below.)

~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

Credit Card Information

(*'d items indicate information we must have to process your order)

*Name on card: ____________________________________________________

*Address of card holder:      __ Same as above        __ Different:

            ___________________________________________________________________

*City/State/Zip:  ________________________________________________________________

*We must have at least ONE of the following two: (preferrably both)

     ~ Phone Number (if different from above):  __________ -- __________ -- ___________________  

     ~ Email Address (if different from above):  ____________________________________________  

(If this is included, you will be sent an e-notification upon processing of your payment.)

*Card Type:     __ MasterCard        __ Visa       __ Discover       __ American Express 

*Card Number:  __________  __________  __________  __________       *Exp. Date:  ____/____

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