District IV Assembly
September 21, 2008
Broad Street Christian Church
Last Name
First Name
Preferred Name
Street Address
City
State
Zip
Phone Number
Email
Congregation
City or Town
Child's Name
Age & Grade
Child's Name
Age & Grade
Registration Form
(Please Note: The cost to attend is $5 per adult, $3 per youth K-12th grade, and $0 for children under
Kindergarten age. Please bring your payment to Broad Street on the day of Assembly.)