MADWR 2021 Meals/ NO Lodging Online Registration 2021 - Meals/NO Lodging MADWR Name* First Last Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email* Text or Videophone NumberText NumberVideophone NumberEnter Your Text or Videophone Number here:*Emergency Contact - Name* First Last RelationText Number*Retreat Theme Shirt (long-sleeves) Pick your size:SMLXL2XL3XLDo you want your name on the shirt?YES, add my name on the shirt - type name belowNO, I don't want my name on the shirtType your name as you want it printed on the shirt:Special Accommodation Need Deaf-Blind Interpreter Special Diet (describe below) Special Diet (include what you cannot eat)Meals/NO LodgingLodging will be on your own Weekend - 5 Meals (Sat. Breakfast - Sun. Lunch) - $75.00Weekend - 6 Meals (Fri. Dinner - Sun. Lunch) - $90.00Saturday Only - 3 Meals (Sat. Breakfast - Sat. Dinner) - $60.00I would like to pay today (Min $5.00 - Max. $90.00)$5.00$10.00$15.00$20.00$25.00$30.00$40.00$50.00$60.00$70.00$75.00$90.00Your Total: $0.00 PAY IN FULL by September 4, 2021. If for some reason you cannot make it to retreat, let us know by September 4, 2021, and you will receive full refund. Debit Card/Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name CAPTCHA