Mail to:
Make checks payable to
Cleveland Area Mensa RG
 , Registrar
2808 Tate Ave
Cleveland OH 44109

Name(s)

________________________________________________________________

Name(s) for badge

________________________________________________________________

Address

________________________________________________________________

City

________________________

State

__________

ZIP

____________

Phone number

(________) ______________________________________________________

Email address

________________________________________________________________

Volunteer to help

Yes    No                            How

____________________________________

 

Number

 

Total

______

of Adult Registrations @ ____________

$____________

______

of Children's Registrations at 1/2 price

$____________

______

of Breakfast buffet (Adult @ $10)

$____________

______

of Breakfast buffet (Child under 12 @ $6)

$____________
 

Total amount enclosed   

$____________