REGISTRATION FORM                                         

                                                 Registration Required by January 25, 2008 or $20 late fee applied

 

Individual Information

Sat dinner

Skate/ pizza

Address/Zip/Email address

Phone

Fee

_____________________________________: ___  

Bahá’í ID _________ Birthdate: ___________  Ethnicity*  ______

Name on nametag (if different from above):

 

 

 

 

 

Name: _____________________________________ Gender: ___  

Bahá’í ID _________ Birthdate: ___________  Ethnicity*  ______

Name on nametag (if different from above):

 

 

 

 

 

Name: _____________________________________ Gender: ___  

Bahá’í ID _________ Birthdate: ___________  Ethnicity*  ______

Name on nametag (if different from above):

 

 

 

 

 

Name: _____________________________________ Gender: ___  

Bahá’í ID _________ Birthdate: ___________  Ethnicity*  ______

Name on nametag (if different from above):

 

 

 

 

 

Name: _____________________________________ Gender: ___  

Bahá’í ID _________ Birthdate: ___________  Ethnicity*  ______

Name on nametag (if different from above):

 

 

 

 

 

*A=Asian   B=Black   H=Hispanic   W=White   NA=Native American P=Persian   MR=Multi-Racial/Cultural    X=Do not identify

       Please consider a contribution in any amount to the scholarship fund

 

Or charge to VISA or MASTERCARD  (Circle one.)

TOTAL

 

Cardholder name: ____________________________________

      

          $25 deposit per youth/adult and $10 each child meal fee with registration

 

 

Card #: ______________________________ Exp. date: ______

 

Balance due upon arrival at school

 

 
Mail Registration form and payment to:       

Florence Mayberry Bahá’í School

A. J. Burkhardt, Registrar

P.O. Box 25

Jefferson City, MO 65102-0025

To contact the Registrar: Phone: 314/867-2546 Email: burkhardtaj@yahoo.com

For additional questions contact Leon Stevens at 573-355-1198                    

To contact the Corresponding Secretary Email: kmay1919@yahoo.com

 

Space is NOT reserved until check or credit card info is received by mail.

 

Photo Release

 

Photos taken at the Florence Mayberry Bahá’í School may be used in the school’s website, brochure, and other promotional materials unless the participant specifically requests otherwise.

 

 

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