Occoneechee Lodge 104

2000 Lodge Leadership Development
November 17 - 19, 2000
Wake Christian Academy
5500 Wake Academy Drive
Raleigh, NC  27603

Registration Form
Fill this form out completely. Please print clearly.

Enclosed is my $20.00 participation fee.

Due by November 1, 2000

Send to:   Sharon McDonald, 6406 Whitt Road, Durham, NC  27712


Name:    _____________________________________________________________

Address: _____________________________________________________________

City: ______________________________ State: _______  Zip: _____________

Phone: (______) ______ - _____________

     Circle One					     Circle One

  Youth     Adult             Ordeal          Brotherhood          Vigil


Chapter (circle one)

Can          Elu          Eno          Kio

Lum          Nat          Neu          Nig

Tsu          Waz          Yam


Emergency Contact:                                  Phone No.

Name: ___________________________________________  (_____)  _____ - __________

                                                                                                                       or

Relationship: ___________________________________  (_____)  _____ - __________