Instructions: Print this form and fill it out. Then mail it to the address below.

Name_____________________________________________________________

Address___________________________________________________________

City__________________________________State______Zip________________

Telephones: H ______________________ W ______________________
E-mail (if applies) _____________________________

My conference fee is $________ (fee based on your income. See Cost of Event)

*Scholarship fund donation $________ (optional gift)

AMOUNT ENCLOSED $________ (Please enclose at least half your fee as a deposit. Balance due at event. Make check payable to: Massachusetts Men’s Gathering. Mail check and completed registration form to: MMG, c/o Dennis Donovan, 34 Rush St. Apt 1, Somerville, MA 02145 )

Refund Policy: Your conference fee, less a $20 handling charge, will be refunded if we receive notice at least 7 days before the event or if a replacement attendee is found.

*Your donations make our partial scholarships possible. Don’t let money come between you and MMG. Indicate below if you require financial assistance for this event. We will get back to you.

By my signature on this application, I agree to assume all responsibility for all risk of damage and injury that may occur to me as as a participant in this event. I hereby, for myself, my heirs, executors, and administrators, release and discharge the Massachusetts Men’s Gathering, Clara Barton Camp and all persons associated with this event from all claims, damages, causes of action, present or future, known or unknown, anticipated or unanticipated, which result from, or arise from, or are incident to my participation in this event.

Signature______________________________________Date____________