Pennsylvania Statewide Latino Coalition
Conference Registration Form
Registrant Information
* = required information
*
Last Name:
*
First Name:
Middle:
*
Company / Organization /School Name:
*
Address:
*
City:
*
State:
*
Zipcode:
No home address available
Home Address
*
Address:
*
City:
*
State:
*
Zipcode:
*
Preferred Telephone:
Fax:
*
Preferred Email Address:
Registration Type Selection
*
Registration Type:
Select Registration Type
3 Day Full Package $195
3 Day College $100
3 Day High School $75
Thursday Only $75
Thursday Only College $50
Thursday Only High School $30
Friday Only $100
Friday Only College $60
Friday Only High School $40
Luncheon Only $50
Luncheon Only College $40
Luncheon Only High School $30
Saturday Only $50
Gala Dinner Dance $100pp
Gala Dinner Dance College $75
Gala Dinner Dance High School $50
Dance Only $40pp
Dance Only College $25
Dance Only High School $25
Presenter Conference Day 1 $0
Presenter Conference Day 2 $0
Presenter Conference Day 1 and 2 $0
Total Amount:
Only College and High School students are discounted. All registration rates will increase on and after 10/1/2008.
Special Accommodations, describe:
Please enter the validation code before proceeding
VALIDATION CODE:
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2010-08-01 / 10-1
