IC 2013 - Early Registration January 28 - 31, 2013

Early Registration is available from May 1 - November 15, 2012. Please complete the following information and forward your check to: Interactive Connections, c/o Caroline Cerveny, SSJ-TOSF, 557 Dove Terrace West, Oldsmar, FL 34677.

Thank you for your registration.


  1. F Name


  1. L Name


  1. Title (Mr., Ms., Sr., Fr., Br., other):


  1. Ministry/Job Title:


  1. Parish or Organization:


  1. Address 1:


  1. Address 2:


  1. City:


  1. State:


  1. ZIP:


  1. Office Phone:


  1. Cell Phone:


  1. Home Phone:


  1. Email:


  1. I am an INDIVIDUAL registering for the following (select all of your choices):
    ONLY for the IC Conference (Mon. Eve and Tuesday) - FEE: $60.00
    IC Conference + 1 FETC Day (Monday - Wednesday) - FEE: $150.00
    IC Conference + 2 FETC Days (Monday - Thursday) - FEE: $200.00
    Tuesday Box Lunch - FEE: $20.00
    Tuesday Dinner - FEE: $35.00
    Wednesday Dinner - FEE: $35.00
    ONLY FETC Conference on Wednesday - FEE: $100.00
    ONLY FETC Conference on Thursday - FEE: $100.00


  1. I am interested in registering a group for the conference. Please contact me at (List Your Phone below) for further information.
    Yes
    No


  1. Phone Number:


  1. Registration form and payment must be submitted/postmarked no later than November 15, 2012. All cancellations and requests for REFUNDS will be subject to a $50 administrative fee and $5/person fee and must be postmarked by January 3, 2013. No refunds will be given after that date. I understand this policy.
    Yes
    No


  1. Please list any special needs, including dietary needs:


  1. Comments:


  1. I hereby grant Interactive Connections (User) permission to use my likeness in a photograph in any and all of its publications, including website entries, without payment or any other consideration.

    I understand and agree that these materials will become the property of the "user" and will not be returned.

    I hereby irrevocably authorize the "user" to edit, alter, copy, exhibit, publish or distribute this photo for purposes of publicizing the Digital Discipleship Boot Camp programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph.

    I am 21 years of age and am competent to contract in my own name. I have read this release before choosing "Yes" or "No" below and I fully understand the contents, meaning, and impact of this release.

    Yes
    No