Christian Health Service Corps

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

You can pay in full today or reserve a spot in the workshop by paying a $50 deposit.

Deposit

$50.00

(only choose this option if you are not paying in full today)

Workshop Tuition

$150.00

Qty

Description

Amount

Total

Room and Board at Shalom Retreat Center

$92.50

---

per night

For more information email laura@healthservicecorps.org or call our office at 903-962-4000.

Total: $0.00

Registrant Information

Registrant Name: *

If making a deposit:

How many nights do you plan to stay at Shalom Retreat Center ($92.50/night)?

Are you a member of CMDA?

If registrant address is the same as Payer Information, please answer information after zip code.

Address:

City:

State:

Zip Code:

Gender: *

Age:

Cell Phone: *

Home Phone: *

Email: *

Food Allergies or Intolerances:

Roommate Preference:

(if attending with friend or spouse. Please note name and relationship.)

Do you give us permission to share your contact info with other attendees who would like to share transportation from the airport?

Share Contact Info: *

Payer Information

First Name: *

Last Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

E-mail: *

A receipt will be e-mailed to this address.

Your Payment Information

Name on Card: *

Card Number: *

Security Code: *

Expiration Date: *

Name on Account: *

Routing Number: *

Account Number: *