OmegaFest 2009 Registration Form

Uplift Inc. proudly presents

OmegaFest 2009
152 East McKellar
Memphis, TN 38109
901.946.3442

Conference Registration

REGISTRANTS INFORMATION
Last Name:	First Name:	Middle:	Grade:	Age:	Sex:	Male	Female

Street Address:		City:	State:	Zip:

Primary Phone:	Mobile Phone:	Email Address:		T-shirt Size: (S,M,L, XL or 2XL)



IN CASE OF EMERGENCY
Parent/Guardian Name:		Home Phone No:		Work Phone No:

If under the age of 18, please have parent or guardian sign this form.

Parent/Guaridan Signature (Type name for electronic signature)		Date