Trivia Night Registration
On-Line Registration for the Mini O'Beirne Trivia Night.
 
Requestor:
Name
Address 1
Address 2
City
St
Zip
Phone ( ) -
Cell ( ) -
E-Mail
Please remit payment to:
Mini O'Beirne Crisis Nursery
1011 North Seventh Street
Springfield, Illinois 62702
 
Questions?

Karen L. Cox, LCSW
Executive Director
217-525-6800
FAX 217-525-4043

email: karen@miniobeirne.org

   


Please register my table of 10 ( $100.00).

Please register me for players at $10.00/person.

Player 1
Name
Phone ( ) -
Player 2
Name
Phone ( ) -
Player 3
Name
Phone ( ) -
Player 4
Name
Phone ( ) -
Player 5
Name
Phone ( ) -
Player 6
Name
Phone ( ) -
Player 7
Name
Phone ( ) -
Player 8
Name
Phone ( ) -
Player 9
Name
Phone ( ) -
Player 10
Name
Phone ( ) -
Comment/Request

 
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