DCN300 Registration Form – VIP Guest/Sponsor

DCN300 Registration Form

VIP Guest/Sponsor

Please complete all sections of this form.

Full Name:

Preferred Name (if different):

Organization (if applicable):

Email Address:

Phone Number:

Mailing Address:

Sponsorship/Patronage:

Health & Home – The National Journal of Better Living Annual Journal Subscription

Health & Home Center of Influence, Reading station and/or Community Library

CHAW TAYO – Comprehensive Health Assessment and Wellness Promotion Clinic

Book Lovers Club Members and Community Library Subscribers

My Bible Friends, Bible Treasures, The Bible Story and Uncle Arthur’s Best Stories – Book Lovers Club

Healing Wonders of Herbs, Healing Wonders of Water, Healing Wonders of Diet, Healthy Moves, Healthy Juices and The Blue Zone Project Handbook Advocates and Book Lovers Club

Other (Please Specify)

Contribution Amount (if applicable):

Comments/Special Requests:

Dates of Attendance:

Dietary Restrictions:

None

Vegetarian

Vegan

Gluten-Free

Other

Special Accommodations Required:

Yes

Emergency Contact Full Name:

Emergency Contact Relationship:

Emergency Contact Phone Number:

Emergency Contact Email Address:

Consent and Signature

I hereby certify that the information provided on this form is accurate and complete to the best of my knowledge.

I consent to the use of my information for the purposes of DCN300 event planning and communication.

Signature:

Date:

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