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NAME________________________________________________________

ADDRESS____________________________________________________________

CITY________________________________ PROVINCE/STATE________________

POSTAL/ZIP CODE_______________________________

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I AM A MEMBER OF:

(__) Alcoholics Anonymous

(__) Al-Anon

(__) another 12-step fellowship _______________________

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I AM ENCLOSING:

(__) $25.00 Registration

Please mail this registration form to:

Courage Roundup
c/o 1916 - 1333 South Park St.
Halifax, NS B3J 2K9 Canada

Note: Luncheon on Saturday is included in the registration fee.
Saturday supper is extra; the estimated cost is $10.00, payable at the restaurant.