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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

Exempt


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