Registration Application

Registration Application

Credit Card Payment Method
Enter your information using the proper case - Please do not use ALL CAPITAL OR ALL LOWERCASE LETTERS. Note: some fields are required.

IMPORTANT: Please ensure that your name, PTA position, local unit name, and council are correct -- THIS INFORMATION WILL BE USED TO CREATE YOUR CONFERENCE BADGE. No credentials in last name field, and please do not place quotation marks around any information. Due to space limitations, titles do not appear on badges.
Registrant Name*

First NameLast Name
Email*
example@example.com

Local Unit Demographics
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
YesNo
First Time Attendee

First NameLast Name
PTA Name
District Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Council
District
Enter the name of your local unit, if not found above.
Emergency Contact Information
Select your PTA Position?

Emergency Contact Name*

First NameLast Name
Emergency Contact Daytime Phone*

Area CodePhone Number
Emergency Contact Evening Phone*

Area CodePhone Number

Payment
Secure Payment with Visa, Mastercard, Discover, or American Express

Selection and Payment

Select the applicable registration fee per submission date. Your credit card information is secure. Credit card transactions will be charged a 3% convenience fee. All credit card information is securded via 256-bit SSL encryption. We do not keep your credit card information once this purchase is complete.

One ticket for each lunch and awards dinner is included with full registration. Additional meal tickets are available for purchase. Awards dinner tickets are available for purchase for special guests who will not be attending the Convention.
Attendee Badge ID

Food Allergies
Select Dietary Restrictions and/or Food Allergies*
Add food allergy if not listed above.
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On-Site Registration Package$200.00

Includes Registration Fee, Training Materials, Lunch Friday and Saturday, Meet and Greet Thursday evening and Awards Ceremony (with dinner) on Friday evening. This does NOT include hotel.

Awards Ceremony Dinner$50.00

This is ONLY for Special Guests who will be attending the Awards Ceremony and not attending the Convention, such as principals, nurses and teacher who will be winning awards.

Lunch (Friday)$15.00

Lunch is included with Early Bird and Regular Full Registration. Only order an extra lunch if you need more than one.

Lunch (Saturday) $15.00

Lunch is included with Early Bird and Regular Full Registration. Only order an extra lunch if you need more than one.

Subtotal $0.00Tax $0.00Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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