Name :                                                                                    Private Bungalow    $310                                   

Address:                                                                       Semi-Private  Bungalow @$225/person                        

 City, St Zip :                                                                           Three Man Room @$175/person                        

Home Phone:                                                                               Four Man Room@ $110/person                        

Work Phone:                                                                                             Total Amount:                                  

(If you wish to choose your roommate in a shared room, submit applications for each together.)

Make Checks Payable to
"FRIENDS OF CHOICES"
and mail to  

      If you choose, you may fax this registration for credit card payment to: (310) 915-1973

      Circle one:   American Express         Visa           Mastercard     

                                Total Amount to Charge (from above):                                         

                                                         Card Number:                                                    

                                                     Expiration Date:                                                    

                            Name as it appears on card:                                                            

                     Credit Card billing Address:                                                                  

                              Authorized Signature:                                                                 

                 (Credit Card Transactions will be processed by Baytronics South, Los Angeles, CA.)