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Zeta Phi Beta Sorority, Incorporated State of Illinois ____________________________________________________________________________ Illinois State Leadership Academy – Registration Form Winter Workshops Series for Sorors and Amicae Please type or print legibly.

Last Name

_______________________________

First Name _______________________________

Mailing Address __________________________________________________________________________ Telephone Number ____________________________

E-Mail Address ____________________________

Chapter’s Name

____________________________

Chapter Location __________________________

College/University ____________________________

College/University Location __________________

Registration Status ____ Undergraduate

Financial Status

____ Graduate (Advisor)

____ Graduate (Guest / Presenter)

____ Chapter Basileus

____ Amicae President

____ Amicae

____ Financial

____ Unfinancial

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 $10.00 for enveloped postmarked on or before January 27, 2013. (preferred method + entry in raffle for incentive gift) DO NOT mail registration forms after January 27, 2013. After January 24th, Sorors must register on-site. The on-site registration fee is $15.00 (cash only; no meal preference; no gift; and no raffle entry). Mail the completed form(s) and payment(s) to Zeta Phi Beta Sorority, Incorporated, State of Illinois, c/o Soror Tina Davis, Illinois State Tamias-Grammateus, P.O. Box 439392, Chicago, IL 60634-9392 Mail a copy of the registration form to Soror Connie V. Pugh, P. O. Box 87324, Chicago, IL 60680. 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: ___________________________

Exempt List: Regional Director, State Director, and Workshop Presenters (approved by the State Director).

Please select your sandwich choice and bread type from the list below. Circle R for regular white bread and W for wheat bread. All lunch orders include a sandwich, chips, cookie, and canned soda or bottled water. Please make only one sandwich selection. _____ _____ _____ _____

Turkey Breast with Swiss Cheese Smoked Ham with Swiss Cheese Tuna Salad with Swiss Cheese Roast Beef with Provolone Cheese

R R R R

W W W W

_____ _____ _____ _____

Registrant’s Signature: ____________________________

Cold cut combo Subway Club Vegetarian Sandwich BLT Sandwich

R R R R

W W W W

Date: __________________________________

PLEASE DO NOT WRITE BELOW THIS LINE.

Date Received __________

Amount __________

Check / MO # __________

Cash

Exempt

illinois state.leadership academy.registration form 2013  

Illinois State Leadership Academy Registration 2013