June 22-24, 2012 Long Beach, CA 90802
First Name Last Name
Preferred Name Male Female
City State ZIP Code
E-mail Address Home Phone
Other Phone Best Time To Call
Number of Children Ages of Children
Who referred you? Your Church
Pastor’s Name Pastor’s Phone
Three areas in my life where I’d like to see something new are:
My Purpose for attending the EXPLORE REALITY is…
What would prevent me from attending is….
I am committed to participating in the seminar as scheduled. (Type your name below as your signature.)
How would you like to receive your registration packet?
Via: E-mail US Mail Fax Fax #:
The registration fee* for the Explore Reality is: $350
Registration may be paid through PayPal on the Reinvent Ministries website or by check.
Please make checks payable to Reinvent Ministries and send to: 18627 Brookhurst St. #465 Fountain Valley, CA 92708
You may also e-mail your form to email@example.com or fax it to: : 888-315-1535
Your registration will be confirmed upon receipt of payment.
*Please note that the registration fee is non-refundable.
Registration closes at 6:00 p.m. on the Tuesday before the Seminar