Online Registration Form

A State of Teal Reception

Birmingham Regions Field

September 2, 2014 - 6:00 p.m.

$20 Registration Fee ($21 per ticket if paying via PayPal)


Please complete all fields and submit your registration online. You will be allowed to submit payment either via PayPal or by check.
Name:

 
Address (Street or PO Box):

 
City:

 
State:

 
Zip:

 
Are you a Survivor?
*
Number Attending:

 
Attendees Names ($20 per attendee - please list all names):

 
Phone Number (include area code):

 
Alternate Phone Number (include area code):

 
E-mail Address:

 
T-Shirt Size (insert number by applicable size[s]):
NOTE: Some sizes are unavailable as of 8/21/2014. Do not select these sizes please.

 

 

 
Once you complete your form and click "Submit," you will be taken to an online payment function (PayPal) where you can submit payment online or you will be provided payment information for remittance by check.