2007 National Conference On-Line Registration Form

Name:

Organization/Affiliation:

Position/Title:

Address:

City:   State:   Zip Code:

Phone:   Fax:

Other Phone:

E-mail:

Childcare:   YES        NO      Number of Children:      Ages of Children: 

Special Meals:   Vegetarian      Vegan

Other Special Needs or Translation Needs (please indicate language):

Indicate the fees you wish to pay in the spaces provided:                               

Conference Registration Fees (includes lunch Thurs-Sat)

Individual: $200.00	Low Income: $100.00	Student with ID or 21 and under: $75.00
Organization:$400.00	Conference Sponsor:	Chicago Youth 21 and under with ID: $10.00

Days of Attendance

Thursday

Friday

Saturday

Sunday

If registering an organization, please list up to 3 attendees:

1.  
   phone:     e-mail:

2.  
   phone:     e-mail:

3.  
   phone:     e-mail:

Membership Fees (if you wish to join or renew your membership)

Individual WOC or Ally: $50.00 and up	Low Income/ Student WOC or Ally: $25.00	WOC Organization (Budget under $100,000): $100.00 and up
WOC Organization (Budget $100,000-$500,000): $200.00 and up	WOC Organization (Budget over $500,000): $250.00 and up	Organizational Ally: $250.00 and up

Total Fees to be Paid:  Please record this amount.

When you have completed the form,