Name: _____________________________________
Address: ___________________________________
Apt. #: ____________________________________
City: __________________________ State: ____ Zip: _ _ _ _ _ - _ _ _ _
Telephone (please indicate number where you can be reached most often):
home _ _ _ - _ _ _ - _ _ _ _
work _ _ _ - _ _ _ - _ _ _ _
cell _ _ _ - _ _ _ - _ _ _ _
Email adress: ______________________________
PHiP club affiliation, if applicable: _____________________________________
I am registering these people:
______________________________
______________________________
______________________________
______________________________
______________________________
I/We will be attending:
__ Friday Only ($55 per person)
__ Saturday Only ($95 per person)
__ Friday & Saturday ($130 per person)
__ Saturday & Sunday ($120 per person)
__ Sunday Only ($35 per person)
__ Entire Weekend ($150 per person)
I am enclosing $______ for _____ raffle tickets ($10.00 each) for a chance to win two (2) nights in the Sheraton's Moorefield Suite (August 21 & 22).
Total Payment Enclosed (including raffle tickets): $________.
Please make checks payable to PHC of Richmond.
Mail this form and your payment to:
Cindy Ely
Stars on the Water
12505 Cottage Cove Court
Richmond, VA 23233