Break-A-Way '10 / Group Registration
Please copy & complete the info below so we can be ready for your groups arrival

Name of Group:_______________________________________

Address:_____________________________________________

City:___________________  ST:____  ZIP:___________

Group Leader:________________________________________

Contact Phone #:_____________________________________

E-address: __________________________________________
Please print the names & include at least $20 Regis fee by Sept 17 to reserve their place @ Breakway
Thanks for your help in getting your group to Breakaway - Make checks payable to Oklahoma Chi Apha Campus Ministries & mail to : Breakaway / Chi Alpha;  PO Box 2777; Norman, OK 73070

Your confirmation will be sent to you via e-mail as soon as we receive it & remaining balance will be due @ Breakaway