Breakaway Registration

please complete, copy & submit / then mail regis copy with $20 regis fee by Sept 25 to
Chi Alpha/Breakaway; PO Box 2777; Norman, OK  73070- $25 balance due @ breakaway 
we will be expecting you & will send you an e-mail confirmation

First Name  Last Name

Church/Group Name

Address  

 City     ST    Zip   Gender FM

Phone #  Email  

Age   Birthdate   Are you staying through Sunday?  YN
                                                            (breakfast & Sunday session completed by 12 noon)