B3 Youth Weekend-March 3-5, 2017

2. B3 Youth Weekend Registration-Cost $20
   Friday, March 3rd at 6:30 pm- Paint Night; Saturday, March 4th 9:30 am-Seminar 1:00 pm Dave and Buster

   Friday, March 3rd at 6:30 pm- Paint Night; Saturday, March 4th 9:30 am-Seminar 1:00 pm Dave and Buster

4. Contact Information

6. First Name

7. Last Name

9. Address

11. City

12. State

13. Zip

15. Contact Telephone Number

16. Email

18. Who is attending?

    1. I am registering myself
    2. I am registering someone else

20. First Name

21. Last Name

22. X
    -- Select One --Registration $20

24. Who is attending?

26. First Name

27. Last Name

28. X
    -- Select One --Registration $20

30. First Name

31. Last Name

32. -
    -- Select One --Registration $20

34. First Name

35. Last Name

36. -
    -- Select One --Registration $20

38. Total Number of Participants

39. Total Payment

    Payment will be processed on the next screen.

41. Checks can be mailed to Shiloh Baptist Church-Youth Weekend, 1429 Duke Street, Alexandria, VA 22314

43. Please contact Rev. Mark Montgomery at markmontgomery@shiloh-bc.org for additional assistance.

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45. 1. Receive an email copy of this form.
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