Bash Registration Event will be held at the Antioch VFW on Saturday, April 15, 2023, from 6pm - 11pm. Name(Required) First Last Email(Required) Phone(Required)How would you like to register?(Required) Individual Seat(s) Whole Table Which table package would you like to purchase? Butterfly Table ($350) Captain America Table ($500) How many people are you registering? (Table max=8)Please enter a number from 1 to 8.Person 1 First Last Person 1 Email Person 2(Required) First Last Person 2 Email(Required) Person 3(Required) First Last Person 3 Email(Required) Person 4(Required) First Last Person 4 Email(Required) Person 5(Required) First Last Person 5 Email(Required) Person 6(Required) First Last Person 6 Email(Required) Person 7(Required) First Last Person 7 Email(Required) Person 8(Required) First Last Person 8 Email(Required) Registration Fees Price: $0.00 Total How would you like to make your registration payment?(Required) I will make my payment now by credit card During check-out, payment must be made with credit card. Address 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 Credit Card Payment Information American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Security Code Cardholder Name If mailing a check, please submit the form and then mail your check to: The Butterfly Effect of Maddox J. LoPriore FoundationP.O. Box 265 Lake Villa, IL 60046 (This address will also be emailed to you after your submission).
