Professional Documents
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Registration Form1
Registration Form1
COMMITTEE MEMBERS:
Cecil Clark
Brent Dozier
(708) 935-4292
(214) 460-6083
clc5985@sbcglobal.net
REGISTRATION FORM
First Name: ______________________________ Last___________________________ (Maiden/Nick name) _________________
Name as you would like it to appear on badge:_____________________________________________________________________
Preferred Mailing Address:_____________________________________________________________________________________
City: ________________________________ State: _______________________________ Zip/Postal Code: ___________________
Telephone: (______)____________________ Cell: (______)_____________________ Alternative: (_____)___________________
Email: ____________________________________________________________________________________________________
1.
Registration Fee (Money Order or Cashiers Check):Welcome Packet, 1 T-Shirt, 2 Full Banquet Dinners, 2 Evening Events & Farewell Brunch
(Hotel Accommodations and Airfare not included)
PLEASE CHECK:
BEFORE/ON
$140
$160
$ ___________
$50
$70
$ ___________
2.
Men T-Shirts (Size and Quantity): Medium ___ Large ______ X- Large ____ XX Large____ XXX Large _____
$ ___________
3.
Ladies T-Shirts: (Size and Quantity): Medium ___ Large ____ X- Large ____ XX Large____ XXX Large _____
$ ___________
TOTAL ENCLOSED:
$ __________
4. Please mail completed registration form with payment to: Monica Longmire 55 East 156th St. Harvey, IL 60426
IMPORTANT: ALL REGISTRATIONS MUST BE PAID IN FULL PRIOR TO MARCH 31, 2013
PAYMENT METHOD: Payments can be made in NO MORE than three (3) equal payments PRIOR to Wednesday, October 31, 2012. Make
Cashier/Personal check or Money Order funds payable to: Riley/Markham Reunion. Registration confirmation/receipt and further information will
be mailed.
Cancellations/Refunds Policy: Please consider your attendance and participation in the Reunion carefully. All Reunion expenses are paid in
advance; therefore all registration fees are non-refundable. Event and meals schedules will be sent out prior to July 31, 2012 and can be provided by
contacting any Core Organizer named above.
ADA Compliance: In an effort to inform the Hotel in advance, please list any ADA special needs: _________________________________________