Please copy the form below, complete, and mail by September 20, 2010 with a check (USD) payable to Providence Family Baptist Church:

                Providence Family Baptist Church
                          P.O. Box 2310
                   Lynnwood, WA  98036 USA

Name: __________________________________________

Spouse (if attending):_____________________________

Names  and ages of children:

________________________________________________

________________________________________________

________________________________________________

Phone: _________________________________________

E-mail: ________________________________________________

Address:  ________________________________________________

City: ___________________________________________

State or province: _______________________________

Zip/Postal Code: _______________Country: ________

Home Church: __________________________________

Please check all that apply:

  I need an ADA handicapped accessible room

  I will be staying in an RV at the camp        

  Please reserve a private room

  I would like to share a room with:

________________________________________________

  Conference and meals only           Conference only         

  Please list any food allergies

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