Name:
Church name:

Address:

City, State, Zip:

Phone:

Email:

Registration Fee (required)
Member $30
Non Member $60 ( includes Ordainment/Membership/Fistscription )

Camping Fee (required)
$15/a day
Payable when you arrive

Donation (optional, circle one)
Level : Bobby $1 Squid Lover $5 Crusader for "Bob" $10
Slack Master $23 Salesman $50 Yetinsyn $100
Overman/UberFem $999 Other $

My total is:

PAYMENT:

Money Order Payable to : The SubGenius Foundation

PO Box 181417 Cleveland Heights, OH 44118

Credit Card Type:
Acct. Number:
Exp. Date:

Signature: