17^th Annual Convention Registration Form

                                                                 July 14 – 16, 2011

Company Name:  

Mailing Address:  

City:   State:   Zip:  

 Phone:   Email:  

                        Convention Registration Fee:               $ 195 per person  x  0 1 2 3 4 5 6 people = $

                                        (Includes Basic Registration fee, volleyball tournament, Friday morning educational session & breakfast, Friday night Calcutta auction)

Name of Registrant:    Name of Registrant:

Name of Registrant:    Name of Registrant:

                        + Companion Registration Fee:               $ 150 per person  x  0 1 2 3 4 5 6 people = $

                                         (Includes Basic Registration fee, volleyball tournament, Friday night Calcutta auction, Saturday morning ladies program)

Companion's Name:     Companion's Name:

Companion's Name:     Companion's Name:

                                + Golf Tournament:                              $ 145 per person x  0 1 2 3 4 people = $

Golfer: Score:    Golfer: Score:

Golfer: Score:    Golfer: Score:

                                 + Fishing Tournament:                                               $ 145 per person x  0 1 2 3 4 people = $

Fisherman:   Fisherman:

Fisherman:   Fisherman:

                           + Kids Program:

                                Friday night buffet dinner (Calcutta) - Wristband Required (10 and younger)        $ 45 per child x  0 1 2 3 4 children =  $

                                Friday night buffet dinner (Calcutta) - Wristband Required (11 to adult)            $ 85 per child x  0 1 2 3 4 children =  $

                                          Saturday night (Survivor program) (Ages 4 to 12)                                          $ 65 per child x  0 1 2 3 4 children =  $

Child’s Name: Age: Child’s Name: Age:

Child’s Name: Age: Child’s Name: Age:

                        + Teen Dance:

                                Saturday night 7 to 11 (Ages 13 to 19)                                         $ 25 per teen x  0 1 2 3 4 Teens =  $

Teen’s Name: Age: Teen’s Name: Age:

Teen’s Name: Age: Teen’s Name: Age:

                                + Banquet (Saturday)                                                  $ 140 per person x   0 1 2 3 4 people =  $

Attendee: Attendee:

Attendee: Attendee:

                                                                                                                                                                                     Total:  $  

• Your payment must include the Convention registration fee, plus any activities you select for each person who will be attending. (Convention Registration fee not required for children and teens.)

Method of Payment: Once you submit this page, you will have the option of paying on line, or mailing in a check.  Please select which method you plan on using: On Line    Mail a Check

Please make sure you enter in the correct pricing including the total, then press "Submit".