Registration

Church Name*
Church City*
Association*
Contact Name*
First Last
Church Position (Staff member, volunteer, etc.)*
Contact Phone Number*
Email*
Address*
Street Address City State ZIP Code
Can we email you updates from the Office of Collegiate & Student Ministries*
- Yes
- No
Do you need a deaf interpreter?*
- Yes
- No
Do you need reserved wheelchair access?*
- Yes
- No
What size shirt does the youth leader wear?*
Will you need a special provision for your students? If so, please specify below.*
How many people are you registering for Speak 2021?*
Price: $40.00 Quantity:
How Will You Be Paying?*
- Credit Card
- Check
Coupon
Total
$0.00
Credit Card

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Card Number Expiration Date Security Code Cardholder Name
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