Registration: Weekend Assembly – Area 22 Northern Indiana

Area 22 Service Weekend & Assembly

First Name*

Last Name*

Name on Badge

Address

City

State

Zip

Email*

Phone*

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Registration Options*

$ 175 - Double Occupancy Room

$ 195 - Single Occupancy

$ 35 - Day Pass

Preferred Roommate

Check Number

Payment Method

PayPal / Credit Card

Mail Check / Money Order

On Arrival Cash / Check

Service Position

District Number

Special Requests

When Paying By Check:

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