2025 Archbishop James Patterson Lyke Conference This Little Light of Mine – Celebrating Our Black Catholic Faith Registration Form Participant's Name(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Cell Phone(Required)T-shirt Adult Sizes:(Required) Small Medium Large Extra Large 2 Extra Large 3 Extra Large 4 Extra Large 5 Extra Large Select oneChurch Parish (Arch)Diocese Gender(Required) Female Male Age(Required) 17 and younger 18-40 41 and older Chaperone's Name(Required) Parent/Legal Guardian's Name(Required) I, the above named parent/legal guardian grant permission for my child to participate in these activities endorsed by my church parish that may require transportation to a location away from the parish site. These activities will take place under the guidance and direction of employees and/or volunteers from the above named parish.(Required) Yes No As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the abouve named minor ("participant")(Required) Yes No I confirmed that there are no necessary changes to the Medical Information Consent form for my child that I previously submitted to my church parish. If I have not submitted a form or if there are any necessary changes, I will submit one or complete another Medical Information Consent Form.(Required) Yes No I agree on behalf of myself, my child named herein, and my spouse, our heirs, successors, and assigns, to indemnify, hold harmless, and defend the above named Parish/School, The Roman Catholic Church of the above named (Arch)Diocese and the Lyke Fondation, their members, directors, officers, employees, agents and representatives.(Required) Yes No Lyke Conference Only Price: June 18-20, 2025 Includes Thursday Lunch, T-Shirt and BagAre you attending the Lyke Conference and Rivers Institute(Required) Yes No Lyke Conference & Rivers Institute Price: June 17 - 20, 2025 includes Ring Shout song bookLate Charge Registrations made after May 17, 2025 Price: Registration after May 17, 2025 will include a late fee of $50.00.Are you going to pay with your credit card or mail a check(Required) Credit Card Mail Check Payment MethodPayPal Checkout MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name If you prefer to complete the registration process by sending a check, do the following. Print the completed registration form Make check payable to the LYKE FOUNDATION Mail the form and check to: Lyke Foundation 102 Ann Court Montz, LA 70068 If your registration form is postmark after May 17, 2025, then please add the late registration fee of $50.00 to your balance. Total