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Retreat Registration

Fall CCM Retreat, October 26th and 27th 2004, Sterling Virginia

Please print and mail completed form and a check to:


Mary Chris Beardsley

CCM Conference Coordinator

10024 Downeys Wood Ct
Burke VA 22015

Registration deadline is September 15th, 2004.

Contact Information




Street Address


City ST ZIP Code


Home Phone


E-Mail Address


_____ Enclosed is a check or money order for $100 family conference registration fee.

_____I am attending alone and have enclosed a registration fee of $75.

Who Will Be Joining Us?



_____Mom     ____Dad     ____other


Please list children by name and age (feel free use the back if you need more room):











Total in your party________




Any teens interested in volunteering to help out with the little ones, please let us know!



Teenís Name(s):