*All fields must be completed to ensure proper registration.

Name(s)

Street Address

City      State     Zip Code

Phone Number    E-Mail Address

How did you hear about the conference?  Select One Crossroads Newsletter (Email) 88.3 WAFJ Radio Announcement Television Commercial -- WAGT NBC 26 By visiting Crossroads Counseling Announcement at Church Denominational mail-out Brochure/Flyer Other
What Church are you a member of?

    Ticket Prices: 

         Individual                    $20.00   

Number of Individual Tickets: Session: 9:00 am until 12:00 pm 6:00 pm until 9:00 pm

Method of Payment:    Select One Visa Mastercard Pay via postal mail (by cash or check)    
* If paying by postal mail, please complete this form and mail check to 3665 Wheeler Road, Suite 1B Augusta, Georgia 30909

Name on Card:

Credit Card Number:  (example 1234-5555-1212-7777)   

Expiration Date:  (example  mm/yyyy) 

Total Amount:

Crossroads' mission is to complement and supplement the work of the local church through counseling.  We hope this means not only discipling individuals and families through hard times (counseling), but also evangelism.  If you would like to invite non-Christian friends or family members to a Crossroads event as a part of your Christian witness, we would be honored to have them as our guest free of charge.  Please include their name, address, and phone number in the box below.  We pray that Crossroads will play a role in the advancement of the Gospel your life (discipleship) and in the lives your unsaved loved ones (evangelism) with each event we do.

Special Comments: