Gala Only REGISTRATION FORM

PERSONAL INFORMATION
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Page
For Gala Night Dinner, choose from the entrees below. All entrees are served with butternut charred corn and rice pilaf

For Gala Night Dinner, choose from the entrees below. All entrees are served with butternut charred corn and rice pilafHoney Roasted Chicken Breast. Boneless chicken breast roasted with signature blend of honey and spices then topped with house made honey glazeHoney Roasted Chicken Breast. Boneless chicken breast roasted with signature blend of honey and spices then topped with house made honey glaze

AGENT INFORMATION (extended special discount until Sept 7th only!)

Agent registration is priced at $125 and includes entry to both December 6 and December 7 events, as well as admission to the Gala Night, including a plated dinner.
Agent Code*
Level*
SMD Name*
Licensed*

YesNo

SPOUSE REGISTRATION

Registration is priced at $75 and includes admission to the Gala Night, including a plated dinner.
Will you add your spouse?*

YesNo
Name*

First NameLast Name
Is he / she an Agent?

YesNo
Spouse Agent Code
Is he / she a Licensed Agent?

YesNo
For Gala Night Dinner, choose from the entrees below. All entrees are served with butternut charred corn and rice pilaf

For Gala Night Dinner, choose from the entrees below. All entrees are served with butternut charred corn and rice pilafHoney Roasted Chicken Breast. Boneless chicken breast roasted with signature blend of honey and spices then topped with house made honey glazeHoney Roasted Chicken Breast. Boneless chicken breast roasted with signature blend of honey and spices then topped with house made honey glaze

CHILD REGISTRATION

Kids aged 5 and under attend free of charge and no formal registration fee applies; however, they must still be registered so we can accurately include them in games and other activities. Kids registration (ages 6–17) is priced at $65 and includes admission to the Gala Night, including a plated dinner. Adult child registration is priced at $75 and includes admission to the Gala Night, including a plated dinner.
Will you add child/children in your registration?*

YesNo
How many child (0-5) will you register? Children under 5 are FREE, however, they must still be registered so we can accurately include them in games and other activities.
How many child 6 - 17 years old will you register? *Kids 6-17 of age will be served with chicken alfredo during the Gala Dinner.
How many child 18 an above will you register (non-agent)?
For Gala Night Dinner, choose from the entrees below. All entrees are served with butternut charred corn and rice pilaf

For Gala Night Dinner, choose from the entrees below. All entrees are served with butternut charred corn and rice pilafHoney Roasted Chicken Breast. Boneless chicken breast roasted with signature blend of honey and spices then topped with house made honey glazeHoney Roasted Chicken Breast. Boneless chicken breast roasted with signature blend of honey and spices then topped with house made honey glaze
Sub-Total (USD)
Please list each child’s name and age below and their age group.

PLEASE NOTE THAT THE DEC 5th LEADERSHIP RETREAT IS NOW OPEN FOR ALL!

Retreat registration is priced at $45 per adult. This is an adult-only event; thank you for your understanding.
Would you like to register to this Leadership Retreat?*

YesNo
How many will be registering?
Sub-Total (USD)

PAYMENTS

All registration fees—whether for associates or non‑associates—are transferable but strictly non‑refundable. Should there be any discrepancy between your registration details and payment (for example, the number of persons registered does not match the payment received), you will be contacted via email or telegram to resolve the issue.
PAYMENT SUMMARY

Guest Registration.................................$65

Spouse...................................................${willYou71}

Child Registration..................................${subtotalusd}

5 below................$0 X {howMany54}

6 - 17 yo............$50 X {howMany55}

18 & above.......$65 X {howMany61}
TOTAL (USD)
+ Processing fee (additional 2.9%+0.30)

Payment Amount*

USDDescription

STARR 10th Year Anniversary & Year End Celebration