Print this form and mail.

One form per person please

Utah Area Recovery in the Rockies XIX

Registration Form

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Name___________________________________________________________________________________________

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Address_________________________________________________________________________________________

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City________________________________________________ State____________________ Zip________________

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Phone_________________________________________________________________________________

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E-mail_________________________________________________________________________________

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Special Needs___________________________________________________________________________

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Are you interested in doing service work? Yes_______ No_______

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Pre-Registration (Before August 31st) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00________________

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Basic Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$25.00________________

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Breakfast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$16.00________________

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Banquet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $32.00________________

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Donation to the newcomer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ____________________

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TOTAL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $__________________________

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Make checks payable to:   Recovery in the Rockies

PO Box 866

Salt Lake City, Utah 84110