JLMI MISSIONS CONFERENCE

Name *

First

Last

Address *

street, city, state, zip code

Phone Number *

Email *

How many Adults: List out names *

Example: 2 adults: Pastor Brandon Berry & Pastor Jeanie Berry

Children Attending: Ages 0-5 (List out Name and Age) *

Example: Zaryn Berry age 5, Jewells Berry age 3

Children Attending: Ages 6-12 (List out Name and Age) *

Example: Landyn Berry age 14, Haven Berry age 12

Do Your Children Have Any Special Dietary (allergies, etc) or Care Needs? Please List Below. *

Put n/a or none if it does not apply.

Your Home Church Name *

If you do not currently have a home church say N/A

What meetings attending: *

Are you part of the FIVE FOLD? If so, please specify. *

Will you need hotel arrangements?

PLEASE NOTE: ALL HOTEL RESERVATIONS MUST BE IN NO LATER THAN OCTOBER 4th TO SECURE YOUR ROOM!

If yes, what time are you looking to arrive in town?

If Yes, please let us know what room you will need: *

Phone