Gala Registration Form

Gala Registration Form

Last Registration Day - June 1, 2026
CELEBRATE OUR NATION’S

250th BIRTHDAY

July 3, 2026

at the International Headquarters

in Washington, DC

Black Tie Event
All proceeds to benefit

The Perry Belmont House Foundation

The evening includes:
Food and drinks
10 Piece Orchestra

Silent Auction and much more

Limited number of guests, so plan early.

Further information will be forthcoming. Contact Kathryn Newman for
more information at newmank58@gmail.com or 401-219-2839.
Attendee Information

Please fill name and contact information of attendees. Cost is $500 per person.
Your Name - Attendee 1*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*

Confirmation Emailexample@example.com
Contact Number*
Please enter a valid phone number.
Will you have a additional Attendees with you?*

YesNo
How many additional Attendees would you like to Add?*
Attendee 2*

First NameLast Name
Attendee 3*

First NameLast Name
Attendee 4*

First NameLast Name
Attendee 5*

First NameLast Name
Attendee 6*

First NameLast Name
Attendee 7*

First NameLast Name
Attendee 8*

First NameLast Name
Attendee 9*

First NameLast Name
Attendee 10*

First NameLast Name
Total Reservations
Subtotal of Reservations Payment
PayPal Processing Fee
My Products

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Total Payment Amount
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Attendee Information