First Name (of person(s) registering) 

Last Name

Address City State

Phone e-mail address

Extra people Date

COST

Includes: Noon meal and Supper on Saturday, September 24; Breakfast on Sunday, September 25; Room on Saturday, September 24 [Partial and full scholarships are available – we want all to have the opportunity to meet this great churchman and to have a time away.]Note: We are staying in Mt. Ypsilon Lodge which has one double bed, two stacked bunk beds and a bathroom in each room (bedding/all linens included).

$80 a person based on two in a room

$60 a person based on three in a room

$120 a person based on one in a room

$150 for a family [including children] (up to four people)

Enclosed is my check for Made out to: Mount Olive Lutheran Church, 11500 E Iliff Ave, Aurora, CO 80014 Attention: Nathan Eickmann

Enclosed is my additional check for the scholarship fund (this money will be used as scholarship money and/or to reduce the cost for everyone.)