Please fill out the following information to register for the 2010 PhiDE International Convention. Thank you.
I. INFORMATION
Full Name:
First Name for Name Tag:
Position/Title for Fraternity/Chapter:
College / University:
Chapter Name:
Mailing Address:
City:
State:
Zip:
Telephone:
Fax:
Email:
Arrival Date:
Arrival Time:
SPECIAL NEEDS
Are you or your guest:
Vegetarian
Vegan
Kosher
Vision Impaired
Hearing Impaired
Other - Please Specify:
II.MEMBERSHIP
(You must pay 2009 Dues to attend the Convention)
I am registering as:
A good standing member (dues paying member)
$110 Renewing Graduate Member
$50 Renewing Student Member
III. REGISTRATION
$315 Student Registration Fee
$345 Graduate / Guest Registration Fee
$600 Graduate Couple Registration Fee
$300 Price Saver Student Registration (5 or more per chapter*)
$285 Price Saver Student Registration (10 or more per chapter*)
*This does not count the delegate. All fees are non-refundable.
IV. PLEASE CHECK ALL THAT APPLY
This is my 1st PhiDE Convention
As a Physician, I am interested in becoming a mentor
As a Student, I am interested in becoming a mentee
For listing purposes, please list any special interests:
(Please note 1 Education Session will be based on your interest and needs)
V. MEAL GUARANTEES
Please indicate which meals you WILL attend in order that accurate meal counts may be secured. (These are included in your registration fee)
Thursday:
Meet & Greet 7PM
Friday:
Breakfast 8AM
Scientific Luncheon 12:30PM
VIP Event
Saturday:
Breakfast 8AM
Reception and Dinner 6:30-10PM
VI. GUEST MEAL TICKETS
(Please indicate which meals to which you would like to bring a guest. Your meal is included in your registration).
Friday:
Scientific Luncheon ($50 each)
Saturday:
Reception and Dinner ($85 each)
After submitting your Online Registration to PhiDE, you will be taken
to the payment screen. Thank you.
