- Registration Form -

Please complete all questions and print page to accompany payment

 
Name
 
Street Address
 

City State Zip

 
Phone - -
 
Email
  Please Check:
A.A. Member Al-Anon Member Alateen Member
 

Fee Schedule
Registration $25 per person

Please register early. using the form below, as numbers are extremely limited. Your cancelled check is your receipt. Make check payable to Star City Serenity Weekend and mail to:

Star City Serenity Weekend
P.O. Box 1658
Salem, VA  24153

Questions?  Call Joe Y. (540)312-5824  or Bernard J. (540) 362-2866