CONTACT/ REGISTRANT INFORMATION

NAACP: 11th ANNUAL LEADERSHIP 500 SUMMIT
Rosen Shingle Creek Hotel
Orlando, FL
May 21-24, 2015
Registration Form
Contact/ Registrant Information
Last Name
First Name
Title/Position
Organization
Address I
Address II
City
(
State
)
(
Phone
Zip Code
)
Fax
Email
Special Needs
Special Needs Request
Please explain your special needs and required assistance as addressed by the Americans with Disabilities Act.
________________________________________________________________________________________
Special Meal Request
Vegetarian
Other
____________________________________________________________________________
Workshop Selection
Please select your area(s) of interest:
Civic Engagement/Voting Rights
Criminal Justice
Education
Health
NAACP: 11th ANNUAL LEADERSHIP 500 SUMMIT
Registration Selections
REGISTRATION FEES (Must be postmarked Before April 17, 2015)
$300.00
SPOUSE/ GUEST REGISTRATION
$300.00 (Please include Spouse/Guest Name) ___________________________________________
Youth
$100.00 (Please include Youth's Name (Only 14 and under) _________________________________________________
Total Registration Fees $ ___________________
Payment Options
OPTION I: CHECK/ MONEY ORDER PAYMENT
Please make checks and money orders payable to: NAACP
Mail the check or money order and Registration Form to:
2015 NAACP Leadership 500 Summit
Attn: Tonya Banks
4805 Mt. Hope Drive
Baltimore, MD 21215
OPTION II: CREDIT CARD PAYMENT
Please choose the credit card type
Visa
Mastercard
Discover
American Express
Credit Card Number
3-digit security code
Expiration Date
M M Y Y
________________________________________________________________________
Name (Please provide the name as it appears on the card.)
Billing Address (if different from mailing address)
__________________________________________________________________________________________
Address
__________________________________________________________________________________________
City
State
Zip code
___________________________________________________________
________________________
Authorized Signature ____________________________________________________________
Date ___________________________
IMPORTANT NOTE
All Registrations and payment must be postmarked Before April 17, 2015. Request for cancellation must be received in writing by
April 17, 2015. Cancellation by April 17, 2015 entitles the registrant to a refund of fees (less a $75.00 service fee). Refunds will be
mailed within thirty (30) days following the conclusion of the Summit. We will not be able to refund registration fees for requests
received after April 17, 2015.