REGISTRATION FORM    
     January 27-28, 2012

     Conference Fees 

Early Bird Rate        Conference         with        Fri10/20    Sat10/21

Before 9/30/11        only*                room**        only           only

Early Bird Rate           $75             $120/$95       $40           $60

Regular Rate              $85             $135/$105     $45           $65

At the Door                $95             $145/$115     $50           $70

*Includes Friday dinner, Saturday breakfast & lunch

**Choose between:

    Conference Lodge: room w/2 twin beds (linens incl- limited number)

    Hicks Lodge: group room w/bunk beds (bring your own linens)

Conference Lodge                                  Hicks Lodge

.

Please call Legacy Ministries at 770-742-0790 for information on scholarships and payment

plans.  Students receive a $20 discount.  Tax deductible donations towards scholarships are

gratefully accepted.

.

Please fill out this form and  mail to:

Legacy Ministries

1952 Hwy 54 W  Ste 100

Fayetteville, GA  30214

Name________________________________________________

Phone________________________________________________

Email_________________________________________________

Address_______________________________________________

______________________________________________________

    Amount enclosed :

            Registration            $____________________

            Student Discount   - _____________________

            Donation               +_____________________

            Total Enclosed       $_____________________

                ck number _________        cash _______