Alpha Phi Omega: National Service Fraternity

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Membership Academy Registration Form

To register for the Membership Academy, please fill out the form below, completely and accurately.

The Membership Academy has a maximum capacity of 60 participants. Once 60 people are registered, you may still register, but your registration will go into a waiting list and accepted if space becomes available.
In order to allow the maximum number of chapters and/or extension groups to benefit from this program, we will accept three participants from each group. Once this chapter-based cap has been reached, additional participants registering will be added to the waiting list, and accepted if space is available.
The registration deadline has passed. Thank you for your interest.

Contact Name:


[ First Name ]	[ Last Name ]

Sex:

National Membership Number:

(six-digit number from your membership card; if you leave this blank, the system will attempt to look it up for you. PG/IG members will not have this number - leave it blank)

Chapter/PG/IG:

(if your chapter or extension group is not listed, please contact National Executive Director)

Permanent Address:

Street:
City:
State:
Zip Code:
Home Telephone:	format: xxx-xxx-xxxx

Summer Address:
(unless identical to Permanent)

Street:
City:
State:
Zip Code:
Summer Telephone:	format: xxx-xxx-xxxx

Primary Email Address:

Secondary Email Address:

Status for Fall 2008:

Position:

If, "Other," please specify:

Do you have any special dietary requirements that we need to be aware of?

Please select a method of payment:

If you are paying by credit card: complete this section.

CardHolder's Name:
CardHolder's Contact Number:
CardHolder's Billing Address:	(If different from above)
Credit Card Number:
Credit Card Security Code (CVV2):	A 3-4 digit code that is used to verify that you have physical position of the credit card. Sample: VISA/MC or American Express
Expiration Date:	(MM/DD/YYYY or MM/YYYY)

Please use this space to provide us with any additional information that you feel that you would like to share in order for us to process your registration faster, or to make your Membership Academy experience more enjoyable.

Agreement for Understanding

Please read the following agreement and initial in the box provided.

I have read the course description online and am excited about the opportunity to enhance my skills in the areas of membership recruitment and retention. I promise to take the information and skills as provided to me back to other members of the Fraternity so that I may advance the goals and membership of Alpha Phi Omega.

Furthermore, I understand that my registration is contingent upon space being available, and that I will receive a confirmation from the National Office regarding this confirmation. I also understand that my registration is contingent on payment being received at the National Office by no later than May 29, 2008, whether payment is sent via this website, or a check via US postal mail.

Please review everything that you have entered above and verify to make sure everything has been entered correctly BEFORE SUBMITTING. Once you have verified that everything is correct and complete, press the SUBMIT button. Please press the button only once, even if there is a network delay.