Registration form

3^rd Annual Crop for the Cure

Registration Form

July 23^rd, 2011

To Register

Send this form, with your payment to:

Jackie Barfield
11750 Halcyon Loop
Daphne, AL 36526

Or email me at jackieb410@bellsouth.net

Sorry, no refunds.

Your Information:

Name: ______________________________

Address: ______________________________

City: __________________ St: ____ Zip: _______

Phone: ______________________________

Email: ______________________________

Payment Options ($40.00 prior to 5/25/11 and $50.00 after 5/25/11)

___ Check (payable to Jackie Barfield)

___ Cash (do this only in person)

Seating

Please list the names of all persons you wish to sit with. I will do my best to

accommodate your wishes.

1.______________________________

2.______________________________

3.______________________________

You have an option of receiving one additional raffle ticket

for donating a 2-liter drink or snack to the crop. (Limit 1)

Are you interested? 

__Yes, I will bring _________________________

__ No thank you.

Additional information available at http://daphnecrop.blogspot.com