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I. PERSONAL INFORMATION
*
Name :
*
Title :
*
Organization/Company :
*
Address :
*
City :
*
State :
*
Zip :
*
Email :
*
Hm Tel :
(xxx-xxx-xxxx)
II. JURISDICTIONAL INFORMATION
*
I AM :
Elected
Appointed
Staff
Other
*
JURISDICTION/DISTRICT NAME :
*
OFFICE ADDRESS :
*
CITY :
*
STATE
*
Zip :
*
EMAIL :
*
WK TEL :
(xxx-xxx-xxxx)
WK FAX :
(xxx-xxx-xxxx)
*
Mail Correspondence Preference
Home Address
Office Address
Email Only
III. CONFERENCE REGISTRATION FEES
Full Conference (June 21-23, 2012)
BEFORE 6/8/12
ON-SITE
TOTAL
Non-Member Access Package
Access to all Conference sessions, meals, NALEO evening events and NALEO 5K Run/Walk
$800
$900
$
NALEO Member Access Package
*
Access to all Conference sessions, meals, NALEO evening events and NALEO 5K Run/Walk
*
For NALEO membership information log onto
www.naleo.org/join
$500
$600
$
Elected Official Staff & Spouse Package
Access to all Conference sessions, meals, NALEO evening events and NALEO 5K Run/Walk
$400
$500
$
Student/Youth Package
Access to all Conference sessions, meals, NALEO evening events and NALEO 5K Run/Walk
(Full time High School and College Students must provide current student ID. Youth considered 12 - 17 years of age.)
$300
$400
$
"Your Conference Registration package entitles you to participate in the 3rd Annual NALEO 5K Run/Walk on Saturday, June 23 starting at 8:00 am. Please check below if you would like to be included in this event and indicate your T-Shirt size".
NALEO CONFERENCE POLICY TRACK:
Please indicate the session/track you plan to attend in order of preference:
Please note that the participants should select at least 1 of the session before moving on to the next page.
Yes
No
1
SELECT
HEALTH
EDUCATION
FINANCIAL EMPOWERMENT
CIVIC / POLITICAL PARTICIPATION
BROADBAND ADOPTION
2
SELECT
HEALTH
EDUCATION
FINANCIAL EMPOWERMENT
CIVIC / POLITICAL PARTICIPATION
BROADBAND ADOPTION
3
SELECT
HEALTH
EDUCATION
FINANCIAL EMPOWERMENT
CIVIC / POLITICAL PARTICIPATION
BROADBAND ADOPTION
Please indicate your T-Shirt size
For Adult
Small
Medium
Large
X Large
XX Large
XXX Large
For Youth
Small
Medium
Large
A LA CARTE/ONE-TIME PASSES
Thursday, June 21, 2012
General
Staff/Spouse
Student/Youth
TOTAL
National Leadership Luncheon
$125
$100
$80
$
NALEO Welcome Reception
Complimentary
Complimentary
Complimentary
Friday, June 22, 2012
National Leadership Luncheon
$125
$100
$80
$
DIsney's Magical Main Street Celebration
$100
$75
$25
$
Saturday, June 23, 2012
NALEO 5K Run/Walk
$30
$30
$15
**
$
National Leadership Luncheon
$125
$100
$80
$
NALEO Assembly of Receptions
$100
$75
$25
$
Please indicate your T-Shirt size
For Adult
Small
Medium
Large
X Large
XX Large
XXX Large
For Youth
Small
Medium
Large
**
5K Run/Walk: Student/Youth considered 12 years of age and under.
Total
$
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