REGISTRATION FORM

*** PLEASE PRINT *** *** FILL OUT BOTH SIDES OF FORM ***

Name: ____________________________________________________________________________________

Name on Badge (if different): _________________________________________________________________

Address: ___________________________________________________________________________________

City: ______________________________________________ STATE: ______ ZIP: _______________

Evening Phone: (______) _______-________ Day Phone: (______) ______-________

Email: _____________________________________ Sex: M or F Date of Birth: __________________

Do you wish your name to be included on our conference mailing list? Y or N

*** WORKSHOP REGISTRATION ***

During the conference each participant will attend four workshops. Please list below, in order of preference, the workshops you wish to attend. Every effort will be made to assign you to the workshops of your choice. Workshop assignments will be made on a first come first serve basis. Rank your choices 1 to 3, where 1 is your first choice and
3 is your last choice.

Session I; (Friday AM) 1. ______ 2. ______ 3. ______ Session II: (Friday PM) 1. _____ 2. ______ 3. ________

Session III: (Saturday AM) 1. ______ 2. ______ 3. _____ Session IV: (Saturday PM) 1. _____ 2. _____ 3. ______

*** REGISTRATION DEADLINE ***
*** Postmarked – June 1, 2005 ***

All registrations postmarked & paid in full by the early registration date of 1/2/05 will be eligible for the drawing
for a free registration. A late fee/walk-in fee of $15 will be charged after 6/15/05.

REGISTRATION FEE – Mark spaces(s) that apply

_____ Entire Conference (Thurs – Sun) $350.00
_____ Early Registration Discount (by 2-1-05) - $ 50.00
_____ Late Registration Fee/Walk-in Fee + $ 15.00

Day Rates only (No room/ no breakfast)
_____ Thursday only $25.00
_____ Friday (Day) $85.00
_____ Friday (Eve) $40.00
_____ Saturday (Day) $85.00
_____ Saturday (Eve) $40.00
_____ Sunday Only $25.00

T Shirts ___ S ___ M ___L ____ XL ____ XXL ____ XXXL x $15/ ea = ________

TOTAL: $ _____________

Make checks payable to: International Lutheran Single Adults

Mail this form with $100.00 deposit to: 2005 ILSA Conference, 4217 Glen Hollow Circle - Arlington, TX 76016