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SALT 2011 Online Registration
Trying to register a GROUP??? Use this form instead!


Personal Information
Online Registration ends at midnight (CST) on December 27, 2011



First Name
Last Name
Address
Address
City
State
Zip
Email (registration confirmation will be sent here)
Cell Phone
Gender
Female Male
Campus


Conference Information  


Registration includes 3 nights hotel lodging, 2 lunches, and conference fee.  ($50 included deposit is non-refundable, non-transferrable)

You DO NOT need to contact the hotel for rooms - registration includes housing. Roommate requests can be made below.

Childcare is provided for children ages birth through 5th grade and is included in the registration fee for children.

To register by mail: print form and send to: Chi Alpha SALT Box 1188 Hurst, TX 76053

Mail-In Registrations:  All mail in registrations will be charged an additional $10 manual processing fee if postmarked after Dec. 3rd.

All new on-site registrations will be charged a $10 processing fee.

  Student - Deposit Only - $50
  Student - Full Registration - $184
  Married Students - Deposit Only - $50
  Married Students - Full Payment - $280
  Married Staff  - Deposit Only - $50
  Married Staff - Full Payment - $235
  Single Staff - Deposit Only - $50
  Single Staff - Full Payment - $145
  Alumni / Visitor Pass (no housing, no meals) - $75



Spouse First Name
Number of Children to Register ($40 per child)
0 1 2 3 4
*** IF YOUR CHILD IS YOUNGER THAN 1 YEAR, PLEASE LIST AGE AS "0" ***
Child One First Name
Age

Child Two First Name
Age

Child Three First Name
Age

Child Four First Name
Age

Roommate request


Total Cost:
Total Payment Today:
Remaining Payment Due Onsite:


Credit Card Information
(Credit Cards processed by North Texas District Assemblies of God)

First Name  
Last Name
Exp. Month / Exp. Year
 /   (mm/yyyy) 
Card Type
Card Number


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