Registration Form - Kappa Alpha Psi Fraternity, Inc.

Registration Form - Kappa Alpha Psi Fraternity, Inc.

Registration Form
82 nd GRAND CHAPTER MEETING
Ernest N. Morial Convention Center
New Orleans, LA – August 11-16, 2015
Are you a Senior Kappa (65 or older)? (There will be a special registration area available to service you!) Yes ☐ No ☐ Birth Date (born on or before January 1, 1950) _ Date: Click here to enter a date. First Name: MI: Enter first name Enter initial Last Name: Enter last name Home Address: Enter home street address City: Phone: State: Enter city Enter Phone Number Chapter of Initiation: Current Chapter: Select state Zip: zip code Choose Phone Type Email: Initiation chapter Enter current chapter Initiation Yr.: Countr
y: Enter country Enter preferred email address Initiation year Member ID#: Province: Select Your Province Enter member id # FEES: For Office Use Only
Mailed
FULL REGISTRATION: •
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YOU MUST BE A FINANCIAL MEMBER, AND IN IN GOOD STANDING IN ORDER TO REGISTER. Receipt
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Annual dues paying members-­‐ you "MUST INCLUDE” your 2014-­‐2015 dues with this form. Receipt
Date
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Full registration includes admission to all Business Meetings, the Family Picnic, Undergraduate Leadership Luncheon, Closed Banquet, and the Closed Ball. Returned Receipt
Date:
INDIVIDUAL EVENT TICKETS: Individual event tickets may be purchased. (See price list below.) REGISTRATION (check box to select) Undergraduate Alumni Sr. Kappa (65 +) PRE-­‐REGISTRATION (August 1, 2014 -­‐ December 31, 2014) ☐ $225. 00 ☐ $425. 00 ☐ $375. 00 REGULAR REGISTRATION (January 1, 2014 -­‐ May 31, 2015) ☐ $275. 00 ☐ $475. 00 ☐ $425. 00 REGISTRATION SUSPENDED (June 1, 2015 -­‐ August 10, 2015) NA NA NA ON-­‐SITE REGISTRATION (August 11, 2015 -­‐ August 15, 2015 ☐ $350. 00 ☐ $650. 00 ☐ $550. 00 $ $ (NO PERSONAL CHECKS ACCEPTED ON-­‐SITE.) REGISTRATION SUB-­‐TOTAL: $ PLEASE COMPLETE OTHER SIDE OF FORM. EVENTS BREAKFAST Robert L. Williams Fellowship Breakfast Devotional Breakfast Breakfast Package: Robert L. Williams + Devotional EVENTS Foundation Luncheon Undergraduate Leadership Luncheon Comedy Show Featured Concert Step Show Entertainment Package: Comedy Show + Featured Concert + Step Show Price $25.00 $25.00 $40.00 Qty. Amt. TBA $50.00 $75.00 $100.00 $20.00 $150.00 ALL EVENT PURCHASES SUB-­‐TOTAL: $ DONATIONS UNDERGRADUATE ASSISTANCE – to assist an undergraduate brother in registering, please enter amount. HABITAT FOR HUMANITY – to make a monetary contribution, please enter amount. $ KAPPA ALPHA PSI FOUNDATION ☐ Million Dollar Club ☐ Foundation Club ☐ Other $ ($1,000) ($100 Annually) $ DONATON SUB-­‐TOTAL: $ FINAL PAYMENT AMOUNT REGISTRATION SUB-­‐TOTAL $ EVENT SUB-­‐TOTAL $ DONATION SUB-­‐TOTAL $ TOTAL AMOUNT DUE $ PAYMENT METHOD (Please make check or money order payable to Kappa Alpha Psi Fraternity, Inc.) CARD TYPE: ☐ DEBIT ☐ VISA CARD # Enter credit card number. ☐ MASTERCARD ☐ AMEX EXP. DATE: Month: S elect Month ☐ CHECK Year: Select Year ☐ MONEY ORDER Security Code: Enter Code SIGNATURE -­‐ REQUIRED: DATE: Click here to enter a date. PRINT NAME -­‐ REQUIRED: E-Mail, Mail or Fax to International Headquarters Kappa Alpha Psi Fraternity, Inc.
2322 North Broad Street, Philadelphia, PA 19132-4590
Phone: 215.228-7184 ◊ Fax: 215.228.7181
Email: [email protected]