District Six 58th Annual Conference May 2 - 4, 2014
2014 CONFERENCE REGISTRATION FORM Crowne Plaza Hotel - Springfield 3000 S. Dirksen Pkwy Springfield, IL 62703 Tel: (217) 529-7777 Fax: (217) 529-6666 Please make your own room reservations. Registering for the conference does NOT reserve a room! Conference Registration Deadline date is April 3, 2014 All conference registrations will be confirmed either by email or phone. If you don’t receive a confirmation, you may not be registered. All refund requests are approved by the District Six Board. CLUB NAME MEMBER’S NAME ______________________________________________________________________ ADDRESS CITY
STATE
ZIP
Name preferred on nametag Email address (for reservation confirmation) Daytime phone
Evening phone
Cell phone
In Case of Emergency Contact
Phone
Special Diet? Please describe (Request for special diets must be submitted by April 3, 2014) Disability? Please describe any special accommodations you may need
===================================================================== Check all that apply for the year 2014-2015 CLUB President President Elect Secretary Treasurer
DISTRICT Officer Past Governor District Chairman Governor
INTERNATIONAL Past Intl. President Intl. Officer Intl. Representative Intl. Committee Chair
Please indicate if you will be a delegate or alternate, if this is your first conference, and if you are bringing a guest(s): Delegate Alternate First Timer _ # Guests
REGISTRATION DETAILS Full Conference Registration includes Friday Evening Dinner, Saturday Lunch, Saturday Banquet and Sunday Brunch Received BEFORE April 3, 2014 @ $160 Received AFTER April 3, 2014 @ $175 $ Please select your entrees Saturday Lunch (hot sandwich) Monterey Ranch Chicken or BBQ Pulled Pork Sandwich Saturday Evening Banquet: Pork Medallions or Roasted Prime Rib Partial Registration Saturday only includes Lunch and Banquet @ $120 Please select your entrees Saturday Lunch (hot sandwich) Monterey Ranch Chicken or BBQ Pulled Pork Sandwich Saturday Evening Banquet: Pork Medallions or Roasted Prime Rib Saturday and Sunday only includes Saturday Lunch, Saturday Banquet and Sunday Brunch @ $150 Please select your entrees Saturday Lunch Monterey Ranch Chicken or BBQ Pulled Pork Sandwich Saturday Evening Banquet: Pork Medallions or Roasted Prime Rib Friday Evening Dinner - Non-Registered Guests @ $36 Friday Dinner: Buffet
$36 x
# of guests
Saturday Awards Luncheon - Non-registered Guests @ $25 Please select entree (hot sandwich) Saturday Lunch Monterey Ranch Chicken or BBQ Pulled Pork Sandwich $25 x
$
$
$
# of guests
$
Saturday Evening Banquet - Non-Registered Guests - Please select entree @ $40 Saturday Evening Banquet Pork Medallions or Roasted Prime Rib $40 x____# of guests Sunday Breakfast - Non-registered Guests $20 x # of guests Menu: Scrambled eggs, potatoes, ham served with orange juice, fruit compote, breakfast bakeries, butter and preserves EARLY ARRIVAL SPECIAL TOURS ( includes transportation and box lunch) #1 - Abraham Lincoln Presidential Museum and Elijah Iles House $36 x # of guests OR #2 - Dana-Thomas House (Frank Lloyd Wright designed) and Elijah Iles House $36 x # of guests Please select entrée. ( Includes dessert and beverage)
$_ $
$ $
□Ham/Swiss cheese on Ciabatta Roll □Turkey/Cheddar Cheese on Pretzel Roll □Green salad & grilled chicken “Make and Take” Workshop Bracelet: woven leather with chain
Make checks payable to: Altrusa International Inc. of Springfield, IL
$10 x
# of guests
$
Grand Total $
To cancel a reservation and receive a refund (less $25 Non-refundable fee), a written request must be received on or postmarked by April 3, 2014. All refund requests are approved by the District Six Board and will be processed within 60 days of the close of the Conference.
Mail Registration forms to: Ann Walker - 1417 S. Douglas Ave - Springfield, IL 62704 - Phone 217-741-6798 E-mail Ann62704@yahoo.com