REGISTRATION

PRE-REGISTRATION FORM

Please complete this form even if you are not attending the optional activities to ensure you have a Name Badge upon your arival.

REGISTRANT'S NAME:
(PREFIX, FIRST, MI, LAST, SUFFIX):

LADY'S FIRST NAME (IF ATTENDING):

ADDRESS:

, IL

DAYTIME PHONE NUMBER:

EMAIL ADDRESS:

COUNCIL NUMBER:

REGISTRANT'S TITLE:

SPECIAL REQUESTS:

SECURITY CODE:

Enter the characters (case sensitive) that appear on the right into this box to complete your registration entries.