2nd Annual NCPSMA Western Convention Workshop

Registration Form for Regular* Members

& their Spouses and/or Guests

Please Print

Name ___________________________________________

Spouse/Guest name(s) (if registering) _________________

Address __________________________________________

City, State, Zip ____________________________________

Name of School System (LEA) _______________________

Office Phone #______________  Fax #_________________

E-Mail  Address___________________________________

Important Needed Information

Will you be staying overnight at Ridgecrest or will you be a daily commuter? Please check one.

Staying at Ridgecrest _______ Daily Commuter________

Do you plan to attend the banquet on Wednesday night?

Yes ____________ No___________

Please Note the following:

Meal tickets for Ridgecrest must be purchased with registration. Meal tickets will not be available for purchase at Ridgecrest.

Additional banquet tickets must be purchased with registration. Banquet tickets will not be available for purchase at Ridgecrest.

There will be no refunds after May 5.

Please complete the following as applicable.

Member* Registration ($50) ____________________

(Includes Banquet)

Spouse or Guest Registration ($50) ______________

(Includes Banquet)

Meal Tickets ($60.00) each ____________________

Additional Banquet Ticket ($35 each) ____________

 (If needed)  

Membership Fee $20 _________________________

 (If not a current member)

Late Member* Registration -Late fee waived for 2010

Late Spouse or Guest Late fee waived for 2010

Total amount enclosed $________________________

Please make checks payable to NCPSMA and mail to NCPSMA, 630 Adams Ridge Road, State Road, NC 28676