First Name

Last Name

Age

Street Address

City

State

Zip

Phone

Your Email

Emergency Contact Name:

Emergency Contact Phone:

Doctor:

Preferred Hospital:

Medical conditions we should be aware of:
(Please include food allergies or dietary needs.)

Are you diabetic?

yesno

I hereby release Tacoma Christian Center and the Shilo Inn Hotel from all liabilities should anything arise while I am attending this Conference. I agree that if medical charges should occur, I am fully responsible for all debt. I also authorize the Tacoma Christian Center Women’s Board to make any medical decisions necessary should they be unable to reach my emergency contact and I am not able to make the decision on my own accord.

Please check all that apply:

Would like a quiet roomI sometimes snoreI like to stay up lateI get up early
Other info you would like to give:

Transportation:
---I will be driving my own car & willing to transport ladies with me.I would like to carpool with someone (be a passenger).I will be driving by myself.

Roommate selection:
Please list your preferred roommates. If left blank, we will fill for you.

Roommate 1:

Roommate 2:

Roommate 3:

I acknowledge the following:
Registration will be confirmed upon receipt of payment.
If you need to cancel for ANY REASON, you will receive a refund less your registration deposit.
Cancellations after August 9, 2019 WILL REQUIRE FULL PAYMENT REGARDLESS IF YOU ATTEND OR NOT.

You may pay your registration fee in person at Tacoma Christian Center, or by using the PayPal button below.