Please fill out the following information to register for the 2012 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 2010 Dues to attend the RLC)
I am registering as:
A good standing member (dues paying member)
$110 Renewing Graduate Member
$50 Renewing Student Member
III. REGISTRATION
$350 Graduate/Guest Registration fee
$325 Student Registration fee
$650 Graduate couple registration fee
$310 Price Saver Student Registration fee (5 or more per chapter*)
$300 Price Saver Student Registration fee (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 7:00-8:00pm
Friday:
Breakfast 8:00am
Scientific Luncheon 12:30pm
VIP event 7:00pm
Saturday:
Breakfast 8:00am
Reception and Awards Banquet 6:30-10:00pm
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 ($70 each)
Saturday:
Reception and Awards Banquet ($100 each)
After submitting your Online Registration to PhiDE, you will be taken
to the payment screen. Thank you.
