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Cocaine Anonymous Nebraska Area

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2025 – Midwest Regional – Oct. 31 – Nov. 2, 2025

Download the CA Midwest Regional Convention 2025 Registration Form

Convention - Oct 31 - Nov. 2, 2025

Full Name *

TYPE

CA Member

FAMILY/FRIEND/GUEST

Phone Number *

Email *

Full Address/Street/City/State/Zip *

Early Registration - Before Sept. 30, 2025 (Check all that apply) *

Registation Fee $30

Friday Entertainment $20

Saturday Entertainment $30

Total Registration Amt$

Saturday Night Banquet

Chicken $35

Salmon $35

NY Strip $40

Ribeye $45

Vegetarian $30

Total Banquet Amt$

Coffee Donation (Suggested $15)

H&I Newcomer Donation

Pre-Order Unisex SHORT-Sleeve T-Shirt $25 ea.

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Large

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Pre-Order Unisex SHORT-Sleeve T-Shirt $28 ea.

2XLarge

3XLarge

4XLarge

5XLarge

Total SHORT-SLEEVE T-Shirt Amt$

Pre-Order Unisex LONG-Sleeve T-Shirt $26 ea.

Small

Medium

Large

X Large

Pre-Order Unisex LONG-Sleeve T-Shirt $30 ea.

2XLarge

3XLarge

4XLarge

5XLarge

Total LONG-SLEEVE T-Shirt Amt$

Pre-Order PULLOVER HOODIES $40 ea.

Small

Medium

Large

X Large

Pre-Order PULLOVER HOODIES $45 ea.

2XLarge

3XLarge

4XLarge

5XLarge

Total PULLOVER HOODIE Amt$

TOTAL AMOUNT $

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