2012 Black Ministry Family Convocation Registration
“Sing to the Lord a New Song”
July 11-15, 2012
Greensboro, North Carolina
Please circle all that apply:
Rev. Dr. Mr. Mrs. Ms Child 5-12 Youth 13-17
Name ________________________________________________________________________
Mailing Address _____________________________________________________________
City _______________________________________State _____ Zip Code _____________
E-mail __________________________________________
Emergency Contact Name ___________________________________________________
Emergency Contact Phone Number _________________________________________
Congregation Information
Church Name _________________________________________________________________
Mailing Address _______________________________________________________________
City _____________________________________State _____ Zip Code _________________
Phone Number ______________________ LCMS District ___________________________
Immanuel Alumni ___ (If applicable)
Registration Fees Special Needs
Adult: $140.00 ______________ Do you have any dietary restrictions
Child/Youth: $100.00 ______________ Yes ____ No ______
Total Due: ______________ If “Yes”, what? _____________________
Make a copy of this form, fill it out and send to:
COLIBM
C/O Mr. Eugene Wright, Treasurer
1524 Upshire Road
Baltimore, MD 21218