OA Region 5 Assembly Registration

Fort Wayne, Indiana        July 13 & 14, 2012

Registration Deadline:  June 15, 2012

NOTE: All fields in gold are required.      NOTE: Registrations are non-refundable.
First Name:   Last Name:

Address:

City:    State/Province:    Zip/Postal Code:

Phone #:( ) -       Email Address:
Status:   Region Representative    
Lunch:  Lunch on Saturday is provided, pending receipt of your registration by the deadline.

1. Chicken, rice, salad, fruit cup
2. Vegetarian Entrée, rice, salad, fruit cup 3. Cottage cheese & fruit;
salad		 4. None
I represent the Intergroup.

Address:

City:    State/Province:    Zip/Postal Code:

I have been a Region 5 Representative since:  

This is my first Region Assembly.   Yes      No

Registration Fee: (Registrations are not refundable.)

$40 - US Funds (Voting Rep / Non-Voting Alternates)

$25 - US Funds (Visitor Participating in Lunch, Parliamentarian)

$0 - (Region 5 Officers, Trustee, Webmaster, Visitor Not Participating in Lunch)
Committee Selection:

Please indicate below your selection for committee assignment. Please also indicate if you are working on any projects with this committee or if you are the chair of a committee.

Standing Committees:





First Choice:      Second Choice:

I am the Chair of:        I am working on a project for this committee:

I have been on this committee for assemblies.  I would like a change

Committee assignments will be made on a first-come, first-serve basis. If you do not indicate a preference, committees will be filled as needed.

I wish to pre-order these essential documents at $.10 / page:

Revised March Bylaws (9 pgs.)(now on website)
Revised March Policies and Procedures (13 pgs.)(now on website)
Revised March Convention Guidelines (10 pgs.)(now on website)
Agenda (2 pgs.)
Proposed Motions. (- pgs.)

 I wish to order the complete
Region 5 Handbook ($12).
I need help finding a roommate.  I am Male
Female		 Please share my name, email address and phone number with others looking for roommates.

Payment:     I will pay for my registration only.            No payment is required.

My registration will be paid for by:  

I will pay for my registration as well as for:     $40     $25
                                                                           $40     $25
                                                                            $40     $25
                                                                             $40     $25
                                                                              $40     $25

NOTE: All fields in gold are required.    NOTE: Registrations are non-refundable.