Registration Form Nonviolent Resistance Fellowship of Reconciliation's 47th Annual Northwest Regional Conference July 1 - 4, 2005, Seabeck Conference Center, Seabeck, Washington Please fill out name and gender for each person. For more than 4 people use a second form or the back of this one. Please indicate age for each person under 18, and indicate up to 4 workshop choices in the boxes below for each person interested in participating in them, using the numbers from the brochure. Workshop choices are not binding, but are intended to help the planning committee in scheduling. Continue on back or separate paper for special requests. 1) (name) ______________________(F or M) ___ (age) ___ up to 4 workshops ________ __________ _________ ________ Dietary: no red meat |_| vegetarian |_| vegan |_| For Sat. evening: salmon |_| or veg. option |_| Other dietary (such as allergies) _________________________ Volunteer Jobs (more opportunities at Conf.) _________________________ 2) (name) ______________________(F or M) ___ (age) ___ up to 4 workshops ________ __________ _________ ________ Dietary: no red meat |_| vegetarian |_| vegan |_| For Sat. evening: salmon |_| or veg. option |_| Other dietary (such as allergies) _________________________ Volunteer Jobs (more opportunities at Conf.) _________________________ 3) (name) ______________________(F or M) ___ (age) ___ up to 4 workshops ________ __________ _________ ________ Dietary: no red meat |_| vegetarian |_| vegan |_| For Sat. evening: salmon |_| or veg. option |_| Other dietary (such as allergies) _________________________ Volunteer Jobs (more opportunities at Conf.) _________________________ 4) (name) ______________________(F or M) ___ (age) ___ up to 4 workshops ________ __________ _________ ________ Dietary: no red meat |_| vegetarian |_| vegan |_| For Sat. evening: salmon |_| or veg. option |_| Other dietary (such as allergies) _________________________ Volunteer Jobs (more opportunities at Conf.) _________________________ INDICATE Number of people at each room & meals rate Room with private bath, no singles ______ number of people age 17+ @ $158 = ________ ______ number of people age 12 - 16 @ $125 = ________ ______ number of people age 3 - 11 @ $100 = ________ ______ number of people age 0 - 2, free Single room, adults only, shared bath ______ number of people @ $158 = ________ Inn or Reeser, shared bath ______ number of people age 17+ @ $146 = ________ ______ number of people age 12 - 16 @ $110 = ________ ______ number of people age 3 - 11 @ $73 = ________ ______ number of people age 0 - 2, free Pines or Maples, shared bath ______ number of people age 17+ @ $134 = ________ ______ number of people age 12 - 16 @ $101 = ________ ______ number of people age 3 - 11 @ $67 = ________ ______ number of people age 0 - 2, free Other Houses, shared bath ______ number of people age 17+ @ $122 = ________ ______ number of people age 12 - 16 @ $90 = ________ ______ number of people age 3 - 11 @ $60 = ________ ______ number of people age 0 - 2, free Day Use (no meals or lodging) ____ people @$24 for full 3- day conference ________ Subtotal =________ Registration fee @ $50 [$45 if received by May 31!] times the # of people 18 or older = ______ Donation to scholarship fund to help low income people attend conference = _____ Donation to conference to keep registration fees low for everyone = _____ Make checks payable to: FOR Seabeck Conference 2005 Total = ______ (Canadians: Canadian money accepted as if U.S.) Check appropriate boxes Total is enclosed |_| Scholarship of _____ granted, balance enclosed |_| Payment of ____ enclosed, scholarship pending |_| Other - please enclose note |_| Address _______________________________ City ___________________________ State _____ Zip _____________ Phone day (_____)_______-________ eve (_____)_______- ________ (include area code) Email ____________________________________ If different members of your party have different addresses or phone numbers, please provide info on back Check this box if you do not want your phone number or email listed on the conference roster. |_| no tel # |_| no email Special needs, preferences, and other information: (include special access needs, housing preferences such as double bed or twin beds, if you snore loudly, etc.) - please specify on the back of this form |_| Carpooling: I / We have space for ____ riders. I / We _____ (number of people) need a ride. Please return this form by June 1st to: Jean Buskin, 9728 3rd Ave NW, Seattle WA 98117 - Questions to