Adp Registration Form
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1
22014 American Democracy Project and
American Association
The Democracy Commitment National Meeting
of State Colleges and
Universities
Forging Civic Pathways for Students Between Our Institutions
Delivering America’s Promise
June 5–7, 2014 • Marriott Louisville Downtown • Louisville, Kentucky
ADP Registration Form
Full Name _______________________________________________________ First Name for Badge: _______________________________
Title ______________________________________________________________________________________________________________
Institution _________________________________________________________________________________________________________
Mailing Address ____________________________________________________________________________________________________
City/State/Zip _____________________________________________________________________________________________________
Office Phone _______________________
Fax _______________________ Attendee Email ____________________________________
Twitter Handle _____________________________________________________________________________________________________
Emergency Contact _____________________________ Day Ph: _______________________ Evening Ph: ________________________
Guest Name(s) for badge(s): __________________________________________
_____________________________________________
Registration
Registration fee includes all program sessions and materials; opening reception on Thursday; breakfast on Friday; lunch and
closing dinner on Saturday; and refreshment breaks throughout the meeting. All meeting attendees, including presenters, are
expected to pay the full meeting registration fee.
Fees
Quantity
Price
Total
q
Individual Registration
______
$625
$ _______
(only one person attending from an institution)
q
Team Member Registration
______
$545
$ _______
(use if more than one attending from campus)
q
Student Registration
______
$425
$ _______
(pertains to undergraduate students)
q
Non-Member Registration
______
$725
$ _______
q
Guest Registration
______
$125
$ _______
Total Fees:
$ ________
0.00
Other Functions
(see descriptions on reverse side of form)
q
Opening Reception
______
N/C
N/C
(Thurs., June 5
th
—no charge for registered attendees)
q
Civic Health Summit & Working Lunch
______
$ 25
$ _______
(Thurs., June 5
th
civic health initiative participants)
q
Global Engagement Initiative Pre-Conference Session
______
N/C
N/C
(Thurs., June 5
)
th
q
Student Breakfast
______
N/C
N/C
(Sat., June 7
th
—no charge for registered students)
q
Closing Dinner
______
N/C
N/C
(Sat., June 7
th
—no charge for registered attendees)
q
My campus plans on donating a book bag
(filled with supplies)
Total Fees:
$ ________
0.00
Special Services
Participant
Disability Requirement(s): ________________________________________ q medical allergy ________________________
Dietary Restriction(s):
q diabetic
q vegan
q vegetarian
q gluten-free
Guest
Disability Requirement(s): ________________________________________ q medical allergy ________________________
Dietary Restriction(s):
q diabetic
q vegan
q vegetarian
q gluten-free
Payment
q
q
q
q
q
q
Payment Enclosed
AmEx
MasterCard
VISA
Discover
Bill by Invoice
Name (on card): _____________________________________________________ Signature (required): ____________________________________________
Card #: ____________________________________________________________
Expiration Date: _______________
Security Code: ________________
Save completed registration form on your desktop and submit it as an attachment to:
Felicia Durham at
or fax to 202.296.5819
1307 New York Avenue, NW • Fifth Floor • Washington, DC 20005-4701
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