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					                                                                            June 22-24, 2012 Long Beach, CA 90802
First Name                                                       Last Name
Preferred Name                                                   Male                             Female
Street Address
City                                                             State                 ZIP Code
E-mail Address                                                   Home Phone
Other Phone                                                      Best Time To Call
Occupation                                                       Employer
Birthdate                                                        Age
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:
1.
2.
3.

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.)
Signature                                                        Date

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 admin@reinventministries.org 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

				
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