Registration Form (Please print)

Name:____________________________________

Partner’s Name:____________________________

Address:__________________________________

City/Town:________________________________

Province:____________ Postal Code:___________

Phone:___________________________________

Email:____________________________________

# of Conferences Previously Attended:__________

Last year Attended:_________________________

How did you hear about us?__________________

If you were referred by someone, please share their name as they will be entered in a draw:

________________________________________

Please indicate if you or your partner have any dietary concerns:

________________________________________

Please enclose a cheque or money order for the registration of $175 if paid before November 30th 2010. After Nov. 30, registration will be $195.

Please make cheque payable to:
                The Banff Couples Conference Society
                10 Greenwood Crescent
                Spruce Grove, AB T7X 1Y5

Please Note: Hotel accommodations must be booked directly with the hotel by the couple . Couples must stay at the Chateau Lake Louise in order to attend the conference. Please see more information on booking your room and the hotel cancellation policy on the under HOTEL REGISTRATION.

Cancellations on or before Jan 15, 2011 will receive 50% refund. No refunds will be given after this date.

Please Note: We will not provide your information to third parties.