NCR CCSC Registration Form

28-31 March 2011 Columban Father's Retreat House
St. Coulmbans Nebraska 68056
Emergency Phone # 402-291-1920

SUSPENSE DATE: 11 March 2011 @ 5PM

Part 1: General Information

* First Name:

M.I.

* Last Name:

* Grade:

* CAPID:

* Wing:

* Unit Charter #

* CAP Unit of Assignment:

* What is your Chaplain Corps Duty Assignment?

* Mailing Address:

* City:

* State:

* Zip (+4 Optional)

* Home Phone:

* Business Phone:

* Cell Phone:

E-mail Address (This is the address your confirmation E-mail will be sent to as well as any e-mail regarding the College.)

* Position: Please choose one.

Part 2: Scholastic Data

* Years Attended any Region's CSSC Please choose all that apply:

* Did you Graduate from a CSSC?

Yes

No

If yes, when?

If Yes, which region?

* I will be fulfilling my second year within five years of graduating requirement. I want to recieve a NCR/CSSC Diploma upon completion of this event.

Yes

No

* I need a reciept:

Yes

No

* I want Missouri School of Religion CEU:

Yes

No

Part 3: Other Information

* Dietary Issues:

* Faith Group:

* Polo Shirt Size

* Would you like to order a College Polo shirt?

Yes I would Like a Polo Shirt

No, Thank you.

* Driver's License Number

* State Drivers License Issued by:

Part 4: Registration Options: Please Choose One

*

Please Choose Either "Option A" or "Option B"

Option A

Option B

Option "A" for Chaplain Corps personnel staying on campus includes Registration, up to four nights of lodging at Columban's Retreat House, ten meals (including the banquet) and Monday Evening's Social and Refreshments served during class sessions. Fee: $ 150.00

Option "B" for Chaplain Service personnel not staying on campus includes Registration, Banquet, Monday Evening's Social and Refreshments served during class sessions. (LODGING AND MEALS AT YOUR EXPENSE.) Fee: $ 70.00

Part 4: Registration Fee

Make your check payable to North Central Region, CAP. When you complete this form you will recieve a confirmation e-mail. This e-mail will tell you where to send the fee. Thank you for registering for the 2011 NCR CSSC.

* Indicates Response Required

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