LivingSober

Western Roundup

Friday, July 2, 2010 – Sunday, July 4, 2010

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*Online Registration Form (all fields with are required)**
Please do not submit form until you are ready to complete payment.
First name *
Last name *
Name as you want it to appear on badge
Email address *
Enter the name of the person paying here	(ONLY if you are paying for someone OTHER than yourself. Otherwise, please leave BLANK)
Add my address to the Living Sober email outreach list.	Yes	No
	For news & updates throughout the year. (You can unsubscribe at any time)
Mailing Address *
City *
State *
Zipcode *
New Address?	Yes	No
Phone Number
Which program(s) are you in:	AA Al-Anon Other
Special services needed:	ASL Translation Phone Ear (FM Listening Device) Wheelchair Large Print Program

Credit card payment via PayPal must accompany online registration. Please do not submit form until you are ready to complete payment. Online forms submitted without payment are automatically deleted from the registration system.

Please fill out the form and click "Continue" to select your Registration choices.

Remember, your Registration is not complete until you have submitted payment on the PayPal site.

To register more than one person, please complete the registration process separately for each individual.

For scholarships, please register in person when you arrive at the conference.

© 2010 Living Sober