Doctor's Day Registration Form

March 27th at Vermillionville from 11:00 am - 1:00 pm

Non-members will be charged $35/meal or $50/couple.

Please complete the form below.

Your Full Name: *

Phone Number: *

Email Address: *

I am a: Member Non-Member *

For Dinner, I would like: Crawfish
Jambalaya
Kid's Meal
*

Guest #1 Full Name:

Guest #1 is a: Member Non-Member

Guest #1 Dinner Selection: Crawfish
Jambalaya
Kid's Meal

Guest #2 Full Name:

Guest #2 is a: Member Non-Member

Guest #2 Dinner Selection: Crawfish
Jambalaya
Kid's Meal

Guest #3 Full Name:

Guest #3 is a: Member Non-Member

Guest #3 Dinner Selection: Crawfish
Jambalaya
Kid's Meal

Guest #4 Full Name:

Guest #4 is a: Member Non-Member

Guest #4 Dinner Selection: Crawfish
Jambalaya
Kid's Meal

Questions or Comments:

Thank you for registering. We have received your information.

If you have any questions, please contact the Lafayette Parish Medical Society at (337) 232-2860 or email: staff@lpms.glacoxmail.com.