document.write("Registration 2009\n"); document.write("

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Registration Form

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Please fill out the following information and click the submit button. \"*\" indicates mandatory fields.  All currency amounts are US Dollars. 

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Mail payments by check to Debbi Montrose, B'YACHAD 2009, 13985 NW Harvest Ln, Portland, OR 97229, USA.

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*First Name
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*Last Name
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*Email
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*Verify Email
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*Address
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Address2
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*City
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*State / Province
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*Zip / Postal Code
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Country
 
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Home Phone:
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Mobile Phone:
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Registration through May 25, 2009
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  • Dancers $235 (in cabin, sleeps up to 6) \n"); document.write("
  • Non-Dancer (adult family, friends) $200 \n"); document.write("
  • Youth (age 13-17) $125 \n"); document.write("
  • Child (age 5-12) $75 \n"); document.write("
  • Under age 5 are free 
After May 25, 2009
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  • Dancers $285 \n"); document.write("
  • Non-Dancer $250 \n"); document.write("
  • Youth (age 13-17) $125 \n"); document.write("
  • Child (age 5-12) $75 \n"); document.write("
  • Under age 5 are free 
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Number Dancers Dancer Names
Number Non-Dancers Non-Dancer Names
Number Youth Youth Names
Number Children Children Names
Number Under Age 5 Under 5 Names
Total Registration Total # Registered
Roommate Choices
Number DVD Number CD
Total DVD and CD
Grand Total Due
*Payment Method \"If\n"); document.write("\n"); document.write("\n"); document.write("
Check-Mail to Debbi Montrose address above
Credit Card-Please call me for Number and Expiry
Credit Card-Number and Expiry below
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Card Type \n"); document.write("\n"); document.write("
VISA
MasterCard
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Number of each T-Shirt Size (all are men's sizes). Included with registration. Extras, if available, may be purchased on site. Total should be the same as the total number you are registering.
Small Medium Large XLG Total T-Shirts
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Comments/Questions/Concerns

1000 characters remaining.
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