Workshop Registration

Full Name: *

Preferred Name: *

Your preferred name will be printed on your name badge.

Current Chapter Office:

If applicable, please indicate the chapter office in which you are currently serving.

Chapter: *

If Other Please Specify:

Year of Initiation: *

E-Mail Address:

Telephone Number: *

Would you like to purchase a Province 20 t-shirt?: *

Yes

By clicking "Yes" you agree to purchase a Province t-shirt and understand that you are obligated to pay the price of the t-shirt upon your arrival at Workshop.

If yes, what size would you like to order?:

Housing Arrangements: *

Please specify where you will be staying for Workshop. For hotels, please list the hotel name.

When will you be arriving at Workshop: *

Will you be attending the banquet?: *

Yes

Dietary Restrictions:

Please specify any special dietary needs you may have.

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