Lay Voting Member
Ordained Minister - Under Call       Diaconal Minister - Under Call        Associate in Ministry - Under Call
Ordained Minister/Diaconal Minster/Associate in Ministry - Retired
Ordained Minister/Diaconal Minster/Associate in Ministry - Not Under Call
Intern                                   Seminarian                             Visitor

Last Name     Title Pr. Mr. Ms. Mrs. Dr.     First Name     Male     Female
Address   
City                 State         Zip   

Home Phone        Work Phone
E-Mail           

Congregation/Organization Name and Town
Conference unknown NW N NE E Central S SW W

Campus Housing

I will share a double room    Thursday    Friday
    I prefer to room with
    Please assign me a roommate    Male    Female

I prefer a single room    Thursday    Friday

I do not need campus housing

NOTE:  Campus housing will be in Erickson Residence Center--a DORMITORY for college students located at 3151 12^th Avenue, Rock Island. You will need to bring your own pillow and blanket!! No personal room service is available and beds may be arranged "bunk" style in the dormitory. Sheets will be provided for you to make your own bed. Upon leaving (after the assembly has ended) you are requested to remove your bed linens and return them to the check-in desk, along with your room key. For more information, see Housing Information. If you arrive Thursday evening, room keys and room assignments will be issued upon your arrival to Erickson Residence Center. If you arrive on Friday morning, room keys and room assignments will be issued in Centennial Hall Lobby from 8:00 a.m. until noon. After 1:00 p.m. Friday room keys and room assignments will be issued upon your arrival to Erickson Residence Center.

Special Needs

I would like child care at additional cost
    Please list names, ages, and times childcare is needed

I am physically challenged and require

Other

Liturgical Choir

YES, I will participate in the Liturgical Choir

Assembly Fees

Assembly Registration $55.00 per Voting Member (Visitor, if materials desired). .

Assembly Meals
    Friday and Saturday Complete Meal Plan $33.00 OR check choices below  
    Friday Lunch $8.50    Friday Dinner $10.00    Saturday Breakfast $5.50    Saturday Lunch $9.00
    YES, I would like to participate in the World Hunger Meal (bread, soup, beverage) at Saturday Lunch

Campus Housing
    Double $22.00/Single $25.00 per person x 0 1 2 nights                               

                                                                                                              TOTAL FEES: 
Checks should be made payable to Northern Illinois Synod
Payment is appreciated as soon as possible.
Mail check to: Northern Illinois Synod Assembly, Augustana College, Rock Island, IL  61201-2296

Direct questions to Assembly Registrar, Nancy Corey ncorey@nisynod.org 309-794-4004

Your registration is not complete until your payment is received and you receive a verification e-mail from Nancy Corey. Please allow 3 business days for receipt of verification.