Name (first and last):

Name you would like on your name tag:

Email:

Daytime Phone Number:

Evening Phone Number:

Address:

City:

State:

Zip Code:

Country:

Cost: $200.00 Application fee (non-refundable) plus $1000.00 conference fee per person/double room.

If we receive your application before February 27, 2012 you will receive a $100 early registration discount.

Please note, we are only able to accept US funds at this time.

Are you a Pastor?
YesNo

Are you an Alumni?
YesNo

For Alumni - Year of last The Journey/SALTS attended:

You will be given a double room unless you specify otherwise.
Would you like a single? Yes or no:
If you typed yes in the box above please add $200 to your application cost.

The information you submit will be transmitted via a secure email using encryption software to the Open Hearts Office.

I would like you to charge my Credit Card for: Choose an option The Deposit for The Journey The Full Amount

Name as written on the card:

Credit Card Type: Choose your Credit Card Type Mastercard Visa Discover

Credit Card Number:

Expiration Date (xx/yyyy):

Three digit security code on back of card:

Billing Address if different than above: