Odessa Rush Registration

Odessa Rush Registration
Full Name *

First Name Last Name
Date of Birth *

Month Day Year
School *
Gender *

Male Female
Grade *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone *

Area Code Phone Number
E-mail *
Small Group Leader
Adult T-Shirt Size *

Small Medium Large X-Large 2X-Large
One person in my grade I would like to stay with:
Any non-Crossroads member I'm bringing who needs to stay with me:
Parent Name *

First Name Last Name
Parent Signature *
Date Signed *

Month Day Year

My Products

Rush Registration $ 50.00

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

By clicking submit I agree to pay the above total amount according to the card issuer agreement and agree that all payments are nonrefundable.
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