Fillable 2017 Convention Registration Usd Convention_Registration (US Currency) BLACK

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2017 Convention Registration Usd Convention_Registration (US Currency) BLACK

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CONVENTION REGISTRATION FORM
PLEASE COMPLETE BOTH SIDES OF FORM BEFORE MAILING OR FAXING
Additional information such as current office held for distribution of applicable ribbons, will be associated with name and Club number.
Registration Procedures (Please read carefully)
CONNECT WITH US #OI2017
QUESTIONS REGARDING THIS FORM?
Contact us at (800) 500-8130 or email service@optimist.org
Registrant #1 (Please print)
Registrant #2 – GUEST – Member or Non Member (Please print)
Child Registrant (Please check the activities each child will attend)
All registration fees and meals increase $20 after 11:59pm, June 9 and on-site.
Continued on back side...
• Only one registration form needed for each Member and family registering.
• Please visit www.optimist.org/convention to register online with credit card.
• Early bird registration must be postmarked or faxed no later than May 1, 2017.
• All other pre-registrations must be post marked or faxed no later than May 31, 2017, and received at the International Office by June 9, 2017.
District
_____________________________
Club No.
___ ___ ___ ___ ___
Club Name
___________________________________________
Name
_________________________________________________________________
_________________________________________
Address ____________________________________ _________________________ ______________________ _____________
Daytime phone # (____) _________________ Cell # (____) _________________ Email: ____________________________________________
Will you accept text messages for up-to-date Convention events on-site (normal text rates apply) Yes No Carrier:
_____________
Is this your first Convention? Yes No
Check here if you require any special assistance or have any special dietary requirements and specify: ___________________________
In case of an emergency during the convention, contact: Name and phone #
_____________________________________________________
If Registrant #2 is a non-member guest, check here
and skip the next line to Name.
District
_____________________________
Club No.
___ ___ ___ ___ ___
Club Name
___________________________________________
Name
_________________________________________________________________
_________________________________________
Address ____________________________________ _________________________ ______________________ _____________
Daytime phone # (____) _________________ Cell # (____) _________________ Email: ____________________________________________
Will you accept text messages for up-to-date Convention events on-site (normal text rates apply) Yes No Carrier:
_____________
Is this your first Convention? Yes No
Check here if you require any special assistance or have any special dietary requirements and specify: ___________________________
In case of an emergency during the convention, contact: Name and phone #
_____________________________________________________
Middle Initial
City State Zip Code
Last Nickname for badgeFirst
Middle Initial
City State Zip Code
Last Nickname for badgeFirst
PAY WITH US CURRENCY
OPTIMIST INTERNATIONAL
What’s included in a full registration?
• Officer Training – $300 value each
• Workshops – $95 per hour value
• Personal Development – PRICELESS
• Opening Ceremonies – $75 value
• Business Sessions – $75 each = $150 value
• Voting – YOUR VOICE COUNTS!
• House of Optimism (Exhibit Hall) – $25
per day x 3 days = $75 value
• Fellowship – PRICELESS
Four Events (meal included) are planned for the children.
Additional Thursday event (meal not included)
Adult / Child Add $20
Name __________________________ Age ______ Shirt Size ______
Name __________________________ Age ______ Shirt Size ______
Name __________________________ Age ______ Shirt Size ______
Check here if your children require any special assistance/meals. Please specify: ____________________________________________
Thurs Day Thurs Eve Fri Day Fri Eve Sat Day
Continued from previous page – Registration fees (
All rates increase $20 after 11:59pm, June 9 and on-site.)
Al a carte OPTIONAL GROUP MEAL EVENTS
Souvenir T-shirt
Officer Elect Training, Thursday, July 6. Please check the training session you plan to attend
GRAND TOTAL (PLEASE SUM UP ALL LINES ON RIGHT SIDE OF THIS PAGE) $ _________
Method of Payment
Cancellation Policy
Return to:
Mail OR Fax by deadline (see above): Fax: (314) 371-6006
(Credit Card payment only on faxed requests)
Optimist International Convention
4494 Lindell Blvd. * St. Louis, MO 63108
Persons canceling Convention registrations on or before April 1 will receive a full refund of fees paid. Persons canceling between April 1 and
June 19 will receive a refund of all fees paid, less a processing fee of $25 US per registrant. Persons canceling after June 19 will receive no
refund. ALL CANCELLATIONS MUST BE SUBMITTED IN WRITING. NO SHOWS WILL NOT BE REFUNDED.
Please make all checks or money orders payable to Optimist International. Post dated checks not accepted. All returned checks or credit cards
are subject to a $25 fee. To confirm your registration, use one of the following means of payment:
Total Amount $________ Check Money Order Mastercard Visa American Express Discover
Card No. ___________________________________ Card Security Code ___________________ Exp. Date ___________________________
Cardholder’s Name______________________________________ Cardholder’s Signature _________________________________________
All t-shirts are adult sizes only and will feature the Convention logo. A limited supply of shirts will be sold on-site.
Medium ($18) _____ Large ($18) _____ X-Large ($18) _____ XX-Large ($19) _____ XXX-Large ($20) _____
$ _________
Quantity Quantity Quantity Quantity Quantity
Registrant #1 Registrant #2 Price per person (US)
Early Bird Registration (by May 1)
__________ __________ X $210.00
$ _________
Regular Registration (by May 31)
__________ __________ X $260.00
$ _________
Special Incentive Package (by May 1)
__________ __________ X $310.00
$ _________
Special Incentive Package (by May 31)
__________ __________ X $360.00
$ _________
Child #1 Child #2 Child #3 Price per child (US)
Youth Activities (Thur. Eve – Sat Day)
__________ __________ __________ X $145.00
$ _________
Youth Activities (Thur. Day)
__________ __________ __________ X $20.00
$ _________
Members and Member Guests must be registered to attend a meal function
Registrant #1 Registrant #2 Price per person (US)
Member Member Guest
Club President-Elect & Lt. Gov.-Elect Breakfast (Friday, July 7)
__________ __________ X $25.00
$ _________
Appreciation Luncheon (Friday, July 7)
__________ __________ X $40.00
$ _________
Fellowship/Old Timers Breakfast (Saturday, July 8)
__________ __________ X $30.00
$ _________
Presidential Banquet (Saturday, July 8)
__________ __________ X $50.00
$ _________
Non-Member Guests
must be a guest of a registered member - limit one Non-Member Guest per registered Member
Registrant #2 Price per person (US)
Non-Member Guest
Opening Ceremony (Thursday, July 6)
__________ X $25.00
$ _________
Appreciation Luncheon (Friday, July 7)
__________ X $45.00
$ _________
Fellowship/Old Timers Breakfast (Saturday, July 8)
__________ X $35.00
$ _________
Presidential Banquet (Saturday, July 8)
__________ X $55.00
$ _________
Non-Member Guest Name
_________________________________________________________________
Middle Initial LastFirst
Registrant #1 Registrant #2
District Club Fitness Advisory Chair Designate Training,
8am-12pm
District Leadership Development Chair Designate Training,
8am-12pm
District Membership Chair Designate Training, 8am-12pm
District New Club Building Chair Designate Training, 8am-12pm
Registrant #1 Registrant #2
District Secretary-Treasurer Chair Designate Training,
1pm-5pm
Club Secretary-Treasurer Designate Training, 1pm-5pm
Club President-Elect & Lt. Governor-Elect Training, 1-5pm
*SPECIAL INCENTIVE –
Buy a package deal in advance for a savings of $20. Includes full registration, banquet, luncheon and Old Timers’ Breakfast
Package is not available on-site and cannot be divided between attendees.
FOR ADMINISTRATIVE PURPOSES ONLY:
Total $________________ Date ___________ Check # ____________________ Authorization # _______________________________
Four Events (meal included) are planned for the children.
Additional Thursday event (meal not included)
Adult / Child Add $20
Name __________________________ Age ______ Shirt Size ______
Name __________________________ Age ______ Shirt Size ______
Name __________________________ Age ______ Shirt Size ______
Check here if your children require any special assistance/meals. Please specify: ____________________________________________
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2017 Convention Registration Usd Convention_Registration (US Currency) BLACK

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Completed 14 November 2019

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