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