CONTACT INFORMATION
First Name
Last Name
Name as you would like it to appear on your name tag (first and last)
Gender
Summer address
Summer address 2
(Apt, floor, suite, etc. )
City
State
ZIP
Summer phone number
Cell phone
Primary email address
Secondary email
CONFERENCE/TRAVEL INFORMATION
Following completion of this registration form, we will send you a confirmation email containing specific instructions for completing your travel arrangements.
Please select your primary leadership role. This form is only for national leadership members. If you are an official delegate, collegiate attendee or advisor, please use the appropriate form .
Please select your travel method.
DIETARY REQUIREMENTS
Indicate any special dietary requirements.
ACCOMMODATION OPTIONS
By default, a participant will be placed in a double-occupancy, nonsmoking room with another participant of the same gender for three nights. Roommate requests are permitted. Those who choose to pay an additional fee of $65 per night will be assigned a single room. If you would like to take advantage of these accommodation options, please use the fields below. National Foundation trustees will only stay one night.
Roommate request:
Single room request: all that apply):
Option to not stay at conference hotel:
T-SHIRT SIZE
Each participant is provided at no charge with a 2012 Mortar Board National Conference t-shirt. Please select your size below to ensure that appropriate quantities of sizes can be provided. Sizes requested after the May 15 deadline may not be available.
T-shirt size
Small
Medium
Large
Extra Large
XXL
Other
I do not want a FREE conference t-shirt
Other
CONFERENCE RESPONSIBILITIES
I would be interested in presenting or helping with the facilitation of the following:
PAYMENT INFORMATION
Please select your payment method from the list below. Keep in mind that the following fees apply:
Single room nightly fee - $65
Please calculate your total amount due and enter it here
SPECIAL ACCOMMODATIONS
If you require special accommodations to help you attend this meeting, please describe your needs below and a National Office staff member will contact you by phone or e-mail to help with any arrangements. Please request your accommodation before May 16 so staff have time to provide.
ACCEPTANCE OF RESPONSIBILITY AND WAIVER OF LIABILITY/PHOTO RELEASE
1. Personal travel expenses. I understand that travel charges, including but not limited to, checked baggage, overweight or oversized baggage, in-flight food or incidentals, rebooking, and seat preference are my own personal expense.
2. Waiver of liability. I hereby release, discharge, hold harmless, and acquit Mortar Board and its staff and officers and their agents and assigns and Mortar Board’s partners, sponsors, exhibitors and their officers, agents, representatives, employees and assigns from any actions, causes of action, claims or liabilities, now existing or that may arise in the future, that are in any way related to or arise out of my participation in or travel to or from the conference.
3. Photo permission. I grant my permission for my photograph or likeness to be used for promotional purposes of Mortar Board without any expectation of prior approval or compensation.
4. Directory information. I grant my permission for my contact information to be shared with other conference participants in a printed directory made available at the conference.
If you do not want your contact information to be shared with conference attendees, please check this box.
Agree to waiver by initialing here
Date
