| Personal Information | |
| First Name: | ___________________________________________ |
| Last Name: | ___________________________________________ |
| Home Phone: | ___________________________________________ |
| Work Phone: | ___________________________________________ |
| Address: | ___________________________________________ |
| City: | ___________________________________________ |
| Province: | ___________________________________________ |
| Postal Code: | ___________________________________________ |
| E-mail Address: (for e-mail confirmation) |
___________________________________________ |
| Home Church: | ___________________________________________ |
| Payment Information | |
| Credit Card Number: | ___________________________________________ |
| Expiry Date: | ___________________________________________ |
| Name on Card: (if different than above) |
___________________________________________ |
| Phone # of Card Holder: (if different than above) |
___________________________________________ |
| Number of tickets: | ___________________________________________ |
Tickets will be waiting for you at the door the morning of the breakfast.