Fill out then click PRINT at the bottom.

Registering For:
Contact Information
School Name: *
Advisor: *
Title: *
Address: *
City: *  State: *  Zip: *
Phone: *
Fax: *
Email: *
Organizational Facebook Page: www.facebook.com/
Organizational Twitter: www.twitter.com/
Co-op buyer:
Co-op Buyer Email:
Student Co-op buyer:
Student Co-op Buyer Email:
Referred By: *
School Information
Student Population:
Demographics:   
Programming Budget: $
% of Budget Spent on:
Comedy: %
Movies: %
Lectures: %
Novelities: %
Delegate Information
APCA INTERNS: If any of the below delegates are interested in interning at the conference/workshop you are registering for, then check the YES box next to each interested delegate. Click here for the APCA Intern requirements before checking yes. We like to recognize the interns in the conference pogram, please email jess@apca.com your school/board logo.
(List additional delegates separately)
Delegates:
NOTE: All schools registering delegates must be APCA members in good standing or must pay non-member prices.
Yes
Intern		 If Yes
DAY PASS
WHICH DAY?		 Delegate's Name Delegate's Email I am
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10
#11
#12
#13
#14
#15
T-shirt Sizes: Please calculate the total number per size of t-shirts needed for your delegates:
Small
Medium
Large
XL
XXL
Meals: Please let us know the number of special meals you need for your delegates.
# of Vegetarian Meals:
# Non Dairy Meals:
Membership Information View APCA Membership Policies
Choose One:  I am already a member in good standing
 Campus Membership Fees ($299 Annually)
 Registering as a Non-Member
# of Memberships at $299: Qty: Membership Cost: $
Total Cost
Total Membership Cost: $*
Total Delegate Cost: $*
Total Day Pass Fee(s): $ Day Pass Qty:
Total Spousal Fee(s): $*
GRAND TOTAL: $*
Payment Information *
How Do You Wish To Pay? *
Card Type: *
Card Number:
Exp. Date: / *
CVV2: *  What is a CVV2 Number?
Name on card: *
Billing Information *
NOTE: Please fill out your billing address regardless of your payment method.
Billing Address: *
City, State: , *
Zip: *