Church Name:

Pastor Name:

Will your Spouse be Attending?:
Yes No

If Yes, Spouse Name:

Mailing Address:

City:

State:

Zip:

Phone:

E-Mail Address:


Will you attend Dinner after the Service?:
Yes No

For any additional information, please contact the church office at 252-635-6673. 
Thank you for registering for One Night with Dr. B!