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<center><font class="hl"> Mexico Conference Registration Form</font><br><br>
      <font class="hl2">Mexico City, April 8-11, 2004 -- Hearts Knit Together 
in Unity</font></center><br>

	  
      <table width="100%" font class="text" border="1" cellpadding="2" cellspacing="0">
        <tr> 
          <td rowspan="2"><b>Registration Fees -- Weekend Special</b><br>
            Includes 3 nights lodging at the Anglican Center, all meals, and all 
            tours as described in the conference program; does <strong>not</strong> include the 
            transport fare from the airport to the Anglican Center. </td>
          <td>Price until March 7</td>
          <td>$250.00&nbsp;&nbsp;&nbsp;</td>
          <td>$&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</td>
        </tr>
        <tr> 
          <td> Price after March 7</td>
               <td>$300.00&nbsp;&nbsp;&nbsp;</td>
          <td>$&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</td>
        </tr>
       
        <tr>
          <td colspan="4"><b>Donations</b>&nbsp;&nbsp; <em>Affirmation is a non-profit organization--thank you for your generosity</em></td>
         
        </tr>
        <tr>
          <td colspan="3">General Conference Fund</td>
          <td>$&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</td>
        </tr>
        <tr> 
          <td colspan="3">Erwin Phelps Scholarship (helps students and under-employed 
            attend)</td>
          <td>$&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</td>
        </tr>
        <tr>
          <td colspan="4"><b>Annual Membership Renewal</b></td>
        </tr>
        <tr> 
          <td colspan="3"> $20.00 Member; $10.00 Student; $50.00 Sustaining Member </td>
          <td>$&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</td>
        </tr>
       
        <tr> 
          <td colspan="3" align="right"> <b>Total payment</b>&nbsp;&nbsp;&nbsp; </td>
          <td>$&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</td>
        </tr>
        <tr> 
          <td align="left" colspan="4"> Credit Card type & number&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;  Expiration Date: </td>
        </tr>
      </table><br><br>  <font class="hl2">Personal Information</font><br><br>
      Your name: ____________________________________________________________________ <br><br>
      Address: ______________________________________________________________________ <br><br>
      City: __________________________ State: _______ Zip Code: __________ 
	  Country:_____________________ <br><br>
      Phone: ___________________ E-Mail: _____________________________ <br><br>
	  Mission you served in: _______________________________ What years: ____________ <br><br>
	  How would you 
      like your name to appear on your badge and in the Conference Directory? 
      _____________________ <br><br>___ Please do not include me in the Conference Directory 
      (directory is for conference attendees only)<br><br>
	   Please send me a registration 
      confirmation ___ by email ___ by regular mail <br><br>
	  Do you have any special dietary 
      needs we should be aware of? Explain_____________________________________ <br><br>
      Do you have any other special needs we should be aware of? Explain_____________________________________ <br><br>
      What is your proficiency in Spanish? <br><br>1. __ No proficiency. <br>
      2. __ Basic: Can order a meal in a restaurant. <br>
      3. __ Fair: Can describe my daily routine.<br>
      4. __ Good: Can tell an anecdote fluently.<br>
      5. __ Advanced: Can interpret from one language to the other.<br>
      <br>
      Please fill out this section if you already have purchased your plane ticket<br>
      <br>
      What day are you flying in? ______________________&nbsp;&nbsp; Time: __________________ 
      &nbsp;&nbsp;Airline: ______________<br>
      <br>
      What day are you flying out? __________________________&nbsp;&nbsp; Time: 
      __________________ <br>
      <br><br>

<b>
Mail this form with check, money order, or credit card number to:<br><br>

Affirmation c/o Michael Miner<br>
PO Box 6369<br>
Long Beach, CA 90806
</b>

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