Zeta Phi Beta Sorority, Incorporated State of Illinois ____________________________________________________________________________ 2014 Illinois State Leadership Academy – Registration Form Winter Workshops for Youth Auxiliaries Please type or print legibly.
Last Name
_______________________________
First Name _______________________________
Mailing Address __________________________________________________________________________ Telephone Number ____________________________
E-Mail Address ___________________________
Sponsoring Chapter’s Name ____________________
Chapter Location __________________________
Youth Sponsor _______________________________
Sponsor’s Telephone Number ________________
Parent’s Name ________________________________
Parent’s Telephone Number _________________
Registration Status
Archonette (age) ______ ______ Other (please list)
Amicette (age) ______
Pearlette (age) ______
______________________________________________
In the case of an emergency, please contact: Name _______________________________________
Telephone Number _________________________
Additional Information: I have a disability and may require accommodations to fully participate in the workshops. Please described the accommodations needed. __________________________________________________________________ ________________________________________________________________________________________ The registration fee is $5.00 for envelopes postmarked on or before January 20, 2014. DO NOT mail registration forms after January 20, 2014. After January 20th, attendees must register on-site. The on-site registration fee is $15.00 (cash only; no meal preference). Mail the completed form(s) and payment(s) to Zeta Phi Beta Sorority, Incorporated, State of Illinois, c/o Tina Davis, Illinois State Tamias-Grammateus, P.O. Box 439392, Chicago, IL 60643-9392. Mail a copy of the registration form to Connie V. Pugh, P.O. Box 87324, Chicago, IL 60680. (Do not e-mail the registration form to the State Director.) Please make checks or money orders payable to Zeta Phi Beta Sorority, Incorporated, State of Illinois. A fee will be assessed on NSF checks. Total Enclosed: $________
Exempt ________
List Exempt Reason: ___________________________
Please select your meal choice. Please make only one selection. (Ordering from a local pizzeria) _____ Cheese Only
_____ Cheese and Pepperoni
_____ Salad Preferred
_____ Fruit Preferred
_____ Cheese and Sausage
Registrant’s Signature: ________________________________________
Date: ______________________
Parent/Guardian’s Signature: ___________________________________
Date: ______________________
(Required for Youth Auxiliary Members)
PLEASE DO NOT WRITE BELOW THIS LINE. Date Received __________
Amount __________
Check / MO # __________
Cash
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Exempt
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