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Helping Patients Overcome Fear and Anxiety & Fill My Cup Lord: Finding Peace with God in a 24/7 Wireless World
Registration Form
October 10-11, 2008 • Valley Forge, PA

Please PRINT

Name (as on license) ___________________________________________

Nametag preference ___________________________________________

Nurse     Full-time Student      Faculty      Other ___________________

Address ___________________________________________________

City/State/Zip _______________________________________________

Nursing License #: ___________________________________________

NCF Member ID #: _____ _____ _____ _____ Expiration Date ____ / ____

Day Phone (      ) ________________________ Circle: [Home] [Work]

Evening Phone (      ) ________________________ Circle: [Home] [Work]

Email: ______________________________________________

I'd like to share a room with: ______________________________________________

Conference & Retreat - 2 nights lodging: $ 295.00
Conference & Retreat - 1 night lodging: $ 252.00
Conference OR Retreat - 1 night lodging: $ 215.00
Conference only - no lodging: $ 110.00
Retreat Only - no lodging: $ 95.00
NCF Member discount: $10.00 from above fees
Full-time Undergraduate Nursing Student: $35.00
Student NCF Member Conference Fee: $30.00
After September 22, 2008, add $10.00 to each fee

Total amount enclosed: $ ________________________________

Release: In consideration for being accepted and allowed to participate in this conference/project and activities associated with its program and location, I personally assume responsibility for my actions, and release InterVarsity Christian Fellowship/USA® (hereafter InterVarsity®), its Trustees, employees and agents from loss, injury or damage to myself or my property; provided that nothing contained herein shall excuse InterVarsity, its Trustees, employees or agents from responsibility to act with reasonable care for the safety of myself or my property. Any claim or dispute arising from or related to this release shall be settled by mediation and, if necessary, legally binding arbitration in accordance with the Rules of Procedure for Christian Conciliation of the Institute for Christian Conciliation, a division of Peacemaker® Ministries. Judgment upon an arbitration decision may be entered in any court otherwise having jurisdiction. I understand that these methods shall be the sole remedy for any controversy or claim arising out of this release and expressly waive my right to file a lawsuit in any civil court against InterVarsity for such disputes, except to enforce an arbitration decision. I certify that I am competent to sign this Release, and have done so voluntarily.

Signature: ____________________________________ Date: __________________

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