Print out the form and mail it to: Revival Connections, P O Box 516, Hartford VT 05047with check or credit card information

OR - print out the form and fax it to 802-295-1827

OR - e-mail information to info@revivalconnections.org; and pay registration fee at paypal.com using the e-mail address of info@revivalconnections.org.
 

Name(s):

Mailing Address:

City State Zip:

Country:

Phone #:

E-mail:

Special Needs:

Credit Card Information:

Name as appears on card:

Card Number:

Expiration Date:

Total Amount:

Signature for fax or mail:

Makes checks payable to Revival Connections.

Info: Revival Connections, P.O. Box 516, Hartford VT 05047, 802-295-5248, E-mail: info@revivalconnections.org
 
 

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