Shrines of the Black Madonna - Registration
The Year of Restoration -  Redefining and Celebrating Who We Are


Registration


Register today $300.00 per person.




You may complete the online registration using the form below. 
If you prefer to submit your registration on a paper form use
the link above to download and print a form to be submitted
to your region's committee chair.

An online form should be completed for each individual registered.




ONLINE REGISTRATION FORM
Name:
African Name:
Address:
City:
State:
Zip:
Phone: (include area code)
Email Address:
Gender:
Male
Female
T-Shirt Size:
Membership Region
Please Share Your Lodging Plans:
Host Hotel (Friday Only)
Host Hotel (Friday and Saturday)
Other (off-site)
Entree Selection:
Chicken
Beef
Vegetarian
Vegan
Please list any dietary constraints (include food allergies and gluten free restrictions).
Will you need child care?
Yes
No
Arrival Date:
Departure Date:
Airline:
Payment Detail (**To be completed by regional registrar**)
Late fee of $25.00 for registration payments initiated on or after 4/1/2017.  Hotel reservations are to be made and purchased separately. CLICK HERE to Register and Pay for Hotel.