Encouragement Extreme Registration Form

March, 09 2010

* Denotes required information.

*First Name:
*Last Name:
*Address:
*City:*State:*ZIP:

*E-mail:
*Home Phone:
Work Phone:
Cell Phone:

How did you hear about Encouragement Extreme?

Friend / Family Member
Web site
Encouragement Cafe Radio Program
Another Radio Program
Other

If 'Other' please describe:

Hotel Information:

The Embassy Suites - Greensboro
http://www.embassysuitesgreensboro.com

The Embassy Suites in Greensboro offers free shuttle service to and from the Piedmont Triad International Airport (airport code GSO) every hour. You should contact them directly if you have unusual circumstances that require pick-up or drop-off at any other time.

Hotel Registration - (All rooms are double occupancy**):

$99.00 Full Registration - (Rate includes room**, breakfast and lunch on Saturday, access to all sessions, and conference materials)
$50.00 General Session Only - (Rate includes admission to all the general sessions. Room is NOT included, and breakfast or lunch charges are paid by you directly to the hotel.

**If you would like to request a single-occupancy room, please contact us at info@encouragementcafe.com. There will be an increased rate for a single room.

Note: Conference registration must include hotel stay.

If you want to share a room with a specific person, please indicate their name below. Otherwise, we will arrange your accommodations with another conference attendee.

Roommate Name:

Registration Information

Hotel Information: