Section 1 - Participants:

Participant 1:
Name:
Badge Name:
Email:
Phone Number:
Address:
City:
State:
Zip / Postal Code:

Please check all that apply:

Which program(s) are you in:
AA
Al-Anon
Other
Other:

This is my first time registering for WRLS:
Yes
No

This is my new mailing address:
Yes
No

How may we contact you:
Email
Postal mail

Would you like to lead a workshop:
Yes, please!
Not at this time

Participant 2, If applicable:

Please check all that apply:

Which program(s) are you in:
AA
Al-Anon
Other
Other:

This is my first time registering for WRLS:
Yes
No

This is my new mailing address:
Yes
No

How may we contact you:
Email
Postal mail

Would you like to lead a workshop:
Yes, please!
Not at this time

Section 2 - Services:

ASL Translation
Phonic Ear
Wheelchair
Large Print Program

Section 3 - Registration Type:

Early Registration - prior to June 1, 2007
Single $45
Dual $80

Later Registration - after June 1, 2007
Single $55
Dual $100

Section 4 - Scholarship Donations:

Living Sober will never turn anyone away for lack of funds. Please consider making an additional scholarship donation to assist those who cannot afford the registration fee.
$50 (includes Coffee Mug)
$75 (includes T-shirt)
$100 (includes Coffee Mug & T-shirt)
$200 (includes Coffee Mug, T-shirt & Baseball Cap)
$400 (includes Coffee Mug, T-shirt, Baseball Cap & Sweatshirt)

All scholarship donations come with our sincere Thanks, too!

Section 5 - Commemoratives:

Please note: 3X sizes are available only via pre-order.

Embroidered Hoodie Zip Sweatshirt - $44.00
S M L XL 2X 3X
Quantity:
Price: .00

Embroidered 1/4 Zip Sweatshirt - $44.00
S M L XL 2X 3X
Quantity:
Price: .00

Short Sleeve T-Shirt - $17.00
S M L XL 2X 3X
Quantity:
Price: .00

Sleeveless T-Shirt - $16.00
S M L XL 2X 3X
Quantity:
Price: .00

Ringer T-shirt - $25.00
S M L XL 2X 3X
Quantity:
Price: .00

Baseball T-shirt - $28.00
S M L XL 2X 3X
Quantity:
Price: .00

Baseball Cap - $18.00
Yes
Quantity:
Price: .00

Coffee Mug - $10.00
Yes
Quantity:
Price: .00


Sub-Total:
Sales Tax - 8.5%:
Commemoratives Total:

Section 6 - Payment Information:

We accept MasterCard, Visa, Discover and American Express credit cards online. Cash is on-site only. Checks should be mailed to the Post Office Box, please.

Total of Registration and Scholarship Fees:
Total of Commemoratives Pre-Order:
Grand Total:

Credit Card Information:

Number (no dashes or spaces, number only please):
CCID (3 or 4 digit):
Expiritation date (MMDD, please):
Name on Card:
Electronic Signature - type the word YES in the box:
By typing "YES" in the box, I acknowledge and authorize Western Roundup / Living Sober to charge my credit card for the amount listed in the previous section and stated as Grand Total. Without a "YES", we cannot accept payment via online.


Comments:



This form is being submitted using e-mail. Submitting your data will reveal your email address to Western Roundup/Living Sober (WRLSTreasurer@gmail.com). If you wish to not use this form, please print out the Registration Form and send via postal mail. Thank you....