KJG Scholarship Dinner Reservation Form

Name (of person registering as individual or group)

If you're registering for a group - others from your group are not required to register.

First Name

Last Name

Email address of person registering only

Address

Enter address of person registering

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Phone # of person registering only

(###)

###

####

First & Last Names of Guests at your table

List first and last names below (including yourself)

Special Dietary Restrictions

Please note the guest name and dietary restrictions below

Number of Adults

Enter total number of adults (18+) at your table (include yourself)

Total Amount Due (Adults @ $100)

Type number "0" if no adults at your table

Number of Youth

Enter total number of youth (17 & under) at your table

Total Amount Due (Youth @ $50)

Youth rate for ages 17 and under. Enter number "0" if no youth at your table.

Final Amount Due (Adults & Youth)

Add total due for Adults & Youth from above. If paying with debit/credit card, after hitting "submit" button, you will be taken to the donation payment screen to enter your payment.

How will you be paying?

Check box below.

Credit/Debit Card (If paying with debit/credit card, after hitting "submit" button, you will be taken to the donation payment screen to enter your payment.)

Check (mail to KJG Scholarship, PO 55274, Indpls IN 46220)

Payment by check

When can we expect to receive your payment?

Additional Note to the Committee

Anything else we need to know about your reservation?

Total Amount Due

Please enter the total dinner amount due below. If paying with debit/credit card, after hitting "submit" button, you will be taken to the donation payment screen to enter your payment.