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)