REGISTRATION FORM

REGISTRATION FORM

My Brother’s Keeper IV

May 15th, 2004

* Please Note: We will not be accepting registrations at the door! All registrations must be made in advance.

Registration Deadlines and Costs:

Deadline: May 8th, 2004

Conference Cost:

$80 (includes breakfast, lunch and dinner and attendance at all talks)

The minimum payment for registration is $30, with the remainder due by May 8th, 2004.

Please print out this page, fill it in, and mail it with payment, to the following address:

Courage

c/o Church of St. John the Baptist

210 West 31st Street

New York, NY 10001

Name: ___________________________________

Address:__________________________________

_________________________________________

Phone: ____________________________________

Payment Enclosed: ___________________________

Affiliation With Youth (i.e.: school counsellor, youth group leader, concerned citizen, etc.)

___________________________________________________________________

What I hope to get out of this conference:

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