A Cup of Joy Resource Center, Inc

P.O. Box 29711 Columbus, OH 43229

614-847-0276

“Celebrating You”

Single Parent's Day Registration Form

Name_________________________________________________________

Address____________________________________ City_________ State_____ Zip Code_______

Phone _____ _______________ Email__________________________________________

Emergency Contact Information

Name________________________________________________________

Address___________________________________ City__________ State_____ Zip Code________

Phone______ _______________

Are you a single parent? Yes No What are the ages of your children___ ___ ___ ___ ___

Which of the following do you plan to attend on Saturday afternoon? Circle ONE

Shopping Expedition Pampering Session

If you are planning to attend the pampering session. Please circle TWO sessions below for your pampering session.

Manicure Pedicure Facial Massage

Do you have any dietary restrictions? Yes No

If yes please explain_____________________________________________________________________________

Rates are based on number of occupants per room.

$200.00 per person for ONE to a room
$175.00 per person for Two to a room
$150.00 per person for THREE to a room.
$125.00 per person for FOUR to a room

Roommate’s Names

_____________________________________ ______________________________________

_____________________________________ ______________________________________

Unfortunately we will not be able to provide refunds. We apologize for any inconvenience.

Mail completed registration form and fee in money order or bank check to

A Cup of Joy Resource Center

P.O. Box 29711

Columbus, OH 43229