Leadership, Friendship, and Service

Regionals 2009 Registration Form

Please complete the form below to submit your registration for APO Region VII Conference 2009.

Contact Information

First Name: *

Last Name: *

E-mail Address: *

Phone Number: *

Roll Number (optional):

(membership numbers are XXXXXX YYYY – X’s are the National Number, usually 6-digits; Y’s are the Roll Number, usually 3- or 4-digits)

Chapter/School Information

Chapter/School: *

If other, enter Chapter and School:

Membership Information

Membership Status: *

If other, please explain...:

Classification Information

Classification: *

Emergency Contact Information

Primary Contact

Name: *

Relationship: *

Phone Number: *

Secondary Contact

Name: *

Relationship: *

Phone Number: *

Any Special Dietary Needs?

(Vegan, Kosher, allergies, etc.)

Yes/No: *

Yes

If yes, please explain...:

Any medical concerns we should be aware of?

(Allergies, Diabetes, etc.)

Yes/No: *

Yes

If yes, please explain...:

Delegate Status: *

Are you a Life Member?: *

Yes

Are you a Torchbearer?: *

Yes

Are you a member of the 1925 club?: *

Yes

APO LEADS Courses

* We recommended that you participate in no more than one APO LEADS course during the conference. * Courses are subject to cancellation in the event that enrollment minimums are not met. * Indicating you wish to pre-enroll in a course helps us to identify if enrollment minimums are likely to be met. If you pre-enroll and later decide to not participate, please immediately notify regionviiconference@gmail.com – this is necessary so we can provide as much notice as possible to course presenters and other enrollees in the event a course must be cancelled for falling below minimum enrollement. * On-site enrollment may be possible, provided that a course is not full or been cancelled due to insufficient enrollment.

APO LEADS Launch

Do you wish to pre-enroll in APO LEADS’ Launch?: *

APO LEADS Achieve

Do you wish to pre-enroll in APO LEADS’ Achieve? (Prerequisite: Launch): *

If YES, please indicate one::

APO LEADS Discover

Do you wish to pre-enroll in APO LEADS’ Discover? (Prerequisite: Launch): *

If YES, please indicate one::

T-Shirt Size: *

Are you registering for Alumni Day activities ONLY? (Available only to Alumni and Advisors):

Yes