First name

Last name

Cell phone

Email

Workplace/Chapter

Union Position (if any)

Street address

City

State
---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

The registration fee is $25 (to cover meals and materials)
I can cover all my expensesI need a scholarship to help cover some of my expenses (must register by July 15)

Which nights will you need a room?
Friday onlySaturday onlyBoth Friday and SaturdayI don't need lodging

I am comfortable sharing a room ($65/night)
YesNo

Name of preferred roommate

I would prefer my own single room ($125/night)
YesNo

Special lodging requests?

Which meals do you plan to share with us? (Select all that apply)
Friday dinnerSaturday breakfastSaturday lunchSaturday dinnerSunday breakfastSunday lunch

Special dietary considerations?

Need a ride to Whitakers?
YesNo

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