Project Renewal � Tides Center by D5D29A5


                                         Teen Meditation Night
                          Saturday, November 10, 2012 (6:00 pm - 10 pm)
                               Ekoji, 3411 Grove Avenue, Richmond
                                               REGISTRATION FORM

Home Address:

Phone # Home: ___________________________________ Cell:

Emergency contact:
Name: ___________________________________________ Relationship:
City: _____________________________________________ State: _______________ Zip:
Phone # Work: ______________________ Home: ______________________ Cell:
Cost and Deposit:
Suggested $25-$45 donation.

Please submit this form by Friday, November 2nd with your Payment
For online completion of this registration:
Please email this form to: Credit card payment can be made on our website,
1) click on iBme Retreats button; 2) go to Register; 3) click Buy Now button; 4) log in to PayPal account or choose
Don’t have a PayPal Account to pay with credit card; 5) enter all of the required information; 6) in the Description
section, enter retreat date and attendee’s name; 7) review your information, and complete the payment.

To mail in a paper registration:
Please mail the application with your deposit/payment check payable to iBme, PO Box 804, Floyd, VA 24091.

For questions about the application or retreat, contact Erin Hawkins at 804-218-7453 or Joe Klein at 540-239-2838.

I do hereby confirm the consent given you with respect to your photographing or recording me or my child in connection
with the IBME, Inc Teen Retreat. I hereby grant to you the right to use all the motion pictures, photographs, and audio
recordings which you may make of me or my child, and the right to use my name and/or child’s name or likeness in or in
connection with publicly displaying the retreat or any other use of such video, picture, or audio recording.

Teen name (please print clearly) _____________________________ Teen signature
Parent/Guardian name* __________________________ Parent/Guardian signature*
* if teen is under age 18                                      Date:

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