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2021 Winter Seminar: Redeeming Communication
Registration Fee
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Quantity
$30
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per person, please select the number of people you would like to register
0
1
2
3
4
4
Name
*
Prefix
First Name
Last Name
Suffix
Email (contact information is used only for Emmaus communications - you may opt out any time)
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Phone Number
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Address
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
Parish Name and City/Town ("N/A" if not applicable)
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Age (for statistical purposes only)
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select one
Under 20
20-29
30-39
40-49
50-59
60-69
70 or older
I prefer not to answer
How did you hear about this event? Please be specific.
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Please Complete the Following Information for the Second Registrant
Relationship to Registrant #1:
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select one
Spouse/Partner
Child of Registrant #1
Parent of Registrant #1
Other Relative of Registrant #1
Friend of Registrant #1
Other Relationship
Registrant #2 Name
*
Prefix
First Name
Last Name
Suffix
Registrant #2 Email
*
Registrant #2 Phone
*
Same Address as Registrant #1?
*
Yes
No
Registrant #2 Address
*
Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
Registrant #2 Parish Name and City/Town ("N/A" if not applicable)
*
Registrant #2 Age (for statistical purposes only)
*
select one
Under 20
20-29
30-39
40-49
50-59
60-69
70 or older
I prefer not to answer
Please Complete the Following Information for the Third Registrant
Relationship to Registrant #1:
*
select one
Spouse/Partner
Child of Registrant #1
Parent of Registrant #1
Other Relative of Registrant #1
Friend of Registrant #1
Other Relationship
Registrant #3 Name
*
Prefix
First Name
Last Name
Suffix
Registrant #3 Email
*
Registrant #3 Phone
*
Same Address as Registrant #1?
*
Yes
No
Registrant #3 Address
*
Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
Registrant #3 Parish Name and City/Town ("N/A" if not applicable)
*
Registrant #3 Age (for statistical purposes only)
*
select one
Under 20
20-29
30-39
40-49
50-59
60-69
70 or older
I prefer not to answer
Please Complete the Following Information for the Fourth Registrant
Relationship to Registrant #1
*
select one
Spouse/Partner
Child of Registrant #1
Parent of Registrant #1
Other Relative of Registrant #1
Friend of Registrant #1
Other Relationship
Registrant #4 Name
*
Prefix
First Name
Last Name
Suffix
Registrant #4 Email
*
Registrant #4 Phone
*
Same Address as Registrant #1?
*
Yes
No
Registrant #4 Address
*
Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
Registrant #4 Parish Name and City/Town ("N/A" if not applicable)
*
Registrant #4 Age (for statistical purposes only)
*
select one
Under 20
20-29
30-39
40-49
50-59
60-69
70 or older
I prefer not to answer
Please Indicate Your Seating Preferences
Individuals and groups will be socially distanced in accordance with your preferences indicated below.
If this form includes more than one registrant
*
Please seat us together in a group, socially distanced from other groups and individuals
Please seat us separately - each individual registrant requires social distancing
Other (please explain below)
If "Other" above, please specify the seating preferences of your registrants
*
Please list any other registrants you would like to sit with in a group (optional)
Will you partner with Emmaus?
I would like to add a tax-deductible donation to help advance the work of Emmaus (optional)
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Add 3% to my total amount to help cover the payment processing fees