Millennial Influence - Impacting Generations for Generations

Web site by
Beautiful Alchemy.

reGeneration Registration Form
First Name:	Last Name:
Preferred Name:
Address Line 1:	Address Line 2:
City:	State:	Zip Code:
Phone Number:	Cell Phone:
E-mail:
Church:	Church Address:
Church City:	Church State:	Church Zip Code:
Church Phone:
Your Position/Title:	Years in Youth Ministry:
Spouse attending? YesNo	If yes, spouse's full name?
Please pick your top three choices of free time options: (Hold down the CTRL key while clicking to select multiple options.)

Registration: $150/person	$250/person + spouse
After 10/31/2008: $200/person	$300/person + spouse

Registration form and payment must be received in order to secure conference admission. Registration and payment may be submitted online here or by printing the registration form and mailing to:

Millennial Influence
PO Box 181111
Corpus Christi, TX 78480

You can also fax your registration form to 361-937-3699.

Checks should be written to Millennial Influence. All credit card payments must be submitted online.

Conference fee includes box lunch, at least one free time option and light snacks during the sessions. Meals, hotel, and transportation are the responsibility of the attendee.

We are looking forward to seeing you!

Questions? 361-937-3699 or ask@minfluence.com

reGeneration Registration Form