NOTE: You may only register and pay for one ticket or table at a time. Thank you!

BenefitingĀ A Safe Place Domestic Violence Shelter

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* 1. First Name:

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* 2. Last Name:

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* 3. Street Address:

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* 4. City:

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* 5. State:

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* 6. Zip Code:

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* 7. Email

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* 8. Phone Number

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* 9. I would like to receive emails for future events benefiting Mary's House of Hope at A Safe Place and other COMTREA community programs.

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* 10. Payment

You will pay at the end of this survey.
Make checks payable to: A Safe Place

Return to:

COMTREA
ATTN: Mardi Gras
227 East Main Street
Festus, MO 63026

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* 11. Click "PROCEED TO PAYMENT" below to pay online via credit/debit card.
*registration forms will remain pending until payment is received.
*your seat will not be guaranteed until payment is received.

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