First Name   Last Name: 

Telephone:   Work Telephone: 

Address:   

City:   Prov:  BC AB MN Postal Code:

Email (optional):   

Affiliation with Semiahmoo House Society:  Family Member Board Member Community Member External Stakeholder Other

I would like to receive invitations to future Semiahmoo House Society Events  Yes No

I am planning on using the Safe Ride Home Program  Yes No

I would like my tickets at the office for pickup at the door at time of event mailed to the address provided above

Number of Tickets Requested 1 2 3 4 5 6 7 8 9 10 11 12

Guests attending (please include their names and phone numbers):

        Name*                      Phone Number*

1    

2    

3    

4    

5    

6    

7    

8    

9    

10  

11  

12  

By continuing onto the next screen, your information is sent and you agree to purchase the number of tickets identified.  Your registration will be on hold until full payment has been verified.

Thank you.

Please Note:  some users may experience a time limit when entering data. 
If you encounter any technical difficulties with this form, please contact our director of development at 604-536-1242 ext 232.