National Leadership Conference on Student Government Registration Form

Institution Information:

Institution Name:

Institution Name: :: Required- School or Group Name

Advisor Name:

Advisor Phone:

Advisor E-mail:

SGA Website:

SGA Website: :: Format must be: http://www.yoursgasite.com

SGA Org. General E-mail:

SGA Org. General E-mail: :: Required- Please provide a general e-mail address for your organization.

Organization General Phone:

Mailing Address:

Mailing Address 2:

City:

State:

Zip:

Billing Contact Name:

Billing Address (if different):

Billing Address (if different): :: Billing Address- If different than mailing address

Billing Address 2:

City

State:

Zip:

Referred by (school):

Recommend a School:

Attendee Information:

Please provide accurate name for each attendee so nametags can be created correctly. If names are unknown at this time, please indicate attendee's title/position, in each name box, to assure conference participation.

Attendee 1:

Name:

Name: :: Required - Delegate Name

Title/Position:

Title/Position: :: Individual's Title or Position in Organization

Attendee 1 E-mail:

Attendee 1 E-mail: :: Required-E-mail of submitter

Attendee 2:

Name:

Title/Position:

Attendee 2 E-mail

Attendee 3:

Name

Title/Position:

Attendee 3 E-mail:

Attendee 4:

Name:

Title/Position:

Attendee 4 E-mail:

Attendee 5:

Name:

Title/Position:

Attendee 5 E-mail:

Attendee 6:

Name:

Title/Position:

Attendee 6 E-mail:

Attendee 7:

Name:

Title/Position

Attendee 7 E-mail:

Summary Information:

Check or purchase orders for total amount must be mailed with your school's name in the subject line. Make checks or purchase orders payable to Center for Leadership Development, Inc.

Mail checks to: Center for Leadership Development, Inc. Conference Registration Office 2100 Hillview Dr. Manhattan, KS 66502

Please Register those attendees listed above.

Fees will be sent within one week of registering.

Please complete the image verification below before clicking the submit button on this form. This is a precaution against spam being submitted to the form e-mail link.

Form Completion Verification:

Clicked "Submit" button but nothing looks to be happening? Check above for field validation errors.

Partial refunds will be honored before October 1, 2010.

No refunds after October 1, 2010.