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Wednesday Night Supper Reservation Form

Please fill this form out completely to register for our Wednesday Night Supper which is served from 5:35 - 6:15 p.m.
The cost for the meal is as follows for those with reservations:

        $4 per adult (ages 12 & up)
        $1.50 per child (ages 3 - 11)
        $12 maximum per family (household)

You are making a reservation for Wednesday:  APRIL 7, 2010.

This week's menu:  Fried chicken, mashed potatoes, gravy, green beans, biscuits, salad, tea, coffee and dessert.

First and Last Name *
Phone Number (home or cell) *
How many adult meals (ages 12 & up) are you making reservations for?
How many children's meals (ages 3-11) are you making reservations for?
Validation:
Please duplicate the letters and/or numbers you see below to verify that you are a valid user of this form.
These are the letters you will duplicate in the box below.
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