Family and Youth Leadership Conference

Saturday January 8, 2011

Memorial Auditorium, Montclair State University, 1 Normal Ave., Montclair, NJ 07043

Featured Speaker: Dr. Barry Black, Chaplain of the United States Senate

To Register:

1. Complete Workshop Registration form below and submit.
2. Pay registration fee of $20. Online payment available*.

*FYLC registration fee of $20 can be paid now. (Click Donate to pay securely with credit card or Paypal account).
ATTENTION: Registration is now closed. Thank you for your interest in the Family and Youth Leadership Conference.

Workshop Registration Form (ages 12-24)

*All fields with asterisk must be filled in

*Must enter all required fields

First Name*:		Last Name*:
Address*:

City*:		State*:
Phone (999-999-9999):		Cell Phone:
Email Address:
Age (12-24)*:		Church:
Emergency Contact (Parent / guardian if minor):		Phone: