On-Line Registration
 

A.  Participant Information

Name:

Spouse Attending (if applicable):
Co-op:
Mailing Address:
City/State/Zip:
Phone: (please include area code)
Fax: (please include area code)
E-mail:
Please specify the number of each meal you (and spouse, if applicable) will attend:

Wednesday (11/12) breakfast 

Wednesday (11/12) lunch 

Wednesday (11/12) dinner 

Thursday (11/13) breakfast 

Thursday (11/13) lunch 

 
 

B.  Registration Fee Totals:

(An additional $25 late registration fee will be incurred after November 5)

1.  Registration(s) at $175 per participant:

  $ (please enter total for all participants, including those listed in Section E)
2.  Spouse Registration(s) at $100 per spouse participant:  $ (please enter total for all spouses, including those listed in Section E)
3.  Late registration fee at $25 per participant:  Enter total number of participants
 

C.  Payment Information

Credit Card Type:
Credit Card No.:

Credit Card CVV Number:

(3-digit security code on back of credit card for Visa, MC & Disc; 4 digit security code on front of AmEx)

Expiration Date: (please enter as 4 digits only - month & year)
Total Amount Authorized:  $ (please add items 1 & 2 from Section B above to enter here; also please add $25 for each person accounted for in item 3 from Section B)
 

D.  Electronic Signature

By entering your name here, you authorize us to process your registration payment in the amount of the above-listed

"Total Amount Authorized":

 (please type name as it appears on credit card)
 

If you do not have additional participants to register,

click here to go to the bottom of the page to submit registration.
 

E.  Additional Participant Registration

Name:

Spouse Attending (if applicable):
Co-op:
Mailing Address:
City/State/Zip:
Phone: (please include area code)
Fax: (please include area code)
E-mail:
Please specify the number of each meal you (and spouse, if applicable) will attend:

Wednesday (11/12) breakfast 

Wednesday (11/12) lunch 

Wednesday (11/12) dinner 

Thursday (11/13) breakfast 

Thursday (11/13) lunch 

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 

Name:

Spouse Attending (if applicable):
Co-op:
Mailing Address:
City/State/Zip:
Phone: (please include area code)
Fax: (please include area code)
E-mail:
Please specify the number of each meal you (and spouse, if applicable) will attend:

Wednesday (11/12) breakfast 

Wednesday (11/12) lunch 

Wednesday (11/12) dinner 

Thursday (11/13) breakfast 

Thursday (11/13) lunch 

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 

Name:

Spouse Attending (if applicable):
Co-op:
Mailing Address:
City/State/Zip:
Phone: (please include area code)
Fax: (please include area code)
E-mail:
Please specify the number of each meal you (and spouse, if applicable) will attend:

Wednesday (11/12) breakfast 

Wednesday (11/12) lunch 

Wednesday (11/12) dinner 

Thursday (11/13) breakfast 

Thursday (11/13) lunch