Diana Butler Bass Event

Registration Information

Early Bird Registration Fee: $100. After October 1, 2023: $125.

Student Early Bird Fee: $50. Student Fee After October 1, 2023: $75.

Open a printable registration form here

Mail the registration form and your cheque to:

Siloam United Church
1240 Fanshawe Park Road East,
London, ON N5X 3Z8

Make cheques payable to:

Siloam United Church – please note on memo line DIANA BUTLER BASS.

Any questions call us at 519-455-9201.

OR

complete the online form below

Thank you and we look forward to seeing you in November!

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Emergency Contact

Your Institution, organization, church, etc...

Consent for use of your personal image *

Yes, I agree
No, I do not want my image recorded

Individual and group photos may be taken throughout the event. By indicating yes, you agree to the use of your image for promotion and display purposes for the Diana Butler Bass event. By indicating no, you agree to advise those recording your image of your desire not be included.

Dietary Considarations

Yes, gluten-free

Vegetarian selections will be amongst the items being offered. Please indicate if you require gluten-free meal:

Registration Information - Early Bird Registration Fee: $100 (After October 1, 2023: $125) Student Early Bird Fee: $50 (After October 1, 2023: $75) *

General Registration
Student Registration

Total

$ 0.00

Stripe Credit Card *

Card

Name on Card

Diana Butler Bass Event

Registration Information

Open a printable registration form here

OR

complete the online form below

Thank you and we look forward to seeing you in November!

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