Student Registration Form Deadline – May 24th July 16-20, 2017 Name: _________________________________________________________________ Address: ____________________________ City/State/Zip: ____________________ Phone: _________________ DOB: _____________________ Email: ____________________________________ Church _______________________ Parental Consent: Name: ____________________________ Relationship: ________________________ Phone: __________________________ Signature: ____________________________ Please indicate Lodging Choice □ Hotel (Must include adult supervison) I will be sharing a room with: _________________ _________________ _______________________________________ □ Cedaridge Dorms Cost Information Does not include transportation Includes 4 nights lodging and meals Per person Cedaridge Ministries Dorm: $130 Hotel: $475 single / $275 double $210 triple / $175 quad Hampton Inn or Cumberland Inn Williamsburg, Kentucky Area in which you wish to work: _____ VBS _____ Construction _____ Creative Arts (Music, Puppets, Skits) Any Specialized Area? __________________ Other info: ______________________________________________________________ For more information, contact: Ron Lynch: rlynch@madisonassociation.org 256.536.0015 MBA office www.madisonassociation.org