2009 MCBVI Convention Registration Form

Please return form with payment or call (877)254-6393 (before 9pm please) to register.

Name:

Address:

City State Zip:

Phone:

Email:

( ) Registration: $15.00

( ) Ford Museum Tour: $5.00

Meals
( ) Lunch $12.00

Banquet $20.00
( ) Lemon Herbed Breast of Chicken
( ) Vegetarian Stir Fry

( ) Ken Medema Event (no meal): $15.00

Total payment due:

Format choice (Braille, Large Print, Computer CD):

Do you plan to attend the MoPix movie Thursday night?

Do you need bus pickup/dropoff?

Notes:

Please make check payable to VIPP MCBVI Convention and send to:
Casey Dutmer
5940 Bayberry Farms Drive SW Apt 6
Wyoming, MI 49418