Registration Form Regional Assembly 2018 November 16th-17th First Christian Church 114 North 8th Street Nebraska City, NE 68410Name*Home PhoneEmail* Cell PhoneChurch MembershipVoting DelegateClergyRegistrationPlease list each person attendingAdult(s)0123Registration Fees; before Oct 15th: $30 / after Oct 15th: $35Adult's NameAdult's NameAdult's NameYouth (6th-12th grade)0123Registration Fee: TBD*Youth's NameYouth's NameYouth's NameChildren (Birth - 5th Grade)0123Registration Fee: TBD*Children's NameChildren's NameChildren's Name*TBD - to be determined based on the number of children who register. PLEASE indicate the number of children you would like to have participate, and the Regional Office will be in touch with details. Indicating a number of children does not commit you to participation. MealsI/We would like to participate in these meals and conversationsFriday night opening banquet Price: $30.00 Quantity: Lunch Price: $10.00 Quantity: Kids 17yrs and under eat for FREEAccomodationsThere are also other hotels in Nebraska City where you may want to stay, but the Regional Assembly Planning Group has made special, discounted arrangements at two locations:Lied Conference CenterLied Conference Center$109/night I would like to stay at the Lied Center on Friday night, Nov 16th I would like to stay at the Lied Center on Saturday night, Nov 17th Commuter No over night accommodations requested Best Western Inn - Special Regional Assembly Rate of $83.65 per room. If you'd like to stay at the Best Western you are asked to call Best Western in Nebraska City directly at 402-873-7000 to make your own reservations and pay directly to the hotel. I would like to make a donation to the Christian Church in Nebraska Total $0.00 Scholarships may be available through Cotner College Educational Ministries. Contact Rev. Chris Morton, Regional Minister of the Christian Church in Nebraska to apply: firstname.lastname@example.orgCredit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name Alternative payment methodIf you would like to pay by check, please complete this form and mail it along with a check made payable to Christian Church In Nebraska, 237 South 70th Street, Lincoln, NE 6851 pay by check CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.