Register for LNCQ's June Retreat

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Please fill out form completely and click 'Submit' before advancing to Payment section using the link that appears after the form is submitted.

If you have already submitted this form, but had trouble with electronic payment, please do NOT fill this out again, instead contact webcoordinatorLNCQ1996@gmail.com for help. Submitting the form again interferes with the automatic shutoff mechanism that is based on the number of responses we've received.

Email *

First Name *

Last Name *

Phone # (123-456-7890 format)
*

Emergency Contact Name

Emergency Contact Phone Number

Are you a LNCQ member? *

Yes, and I have paid my current dues

No, I would like to join LNCQ and pay dues so I can sign up for retreat

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