RegForm

Second Quarter Conference Registration

Holiday Inn - Surfside Beach, SC

February 9 - 11, 2018

Club Name

Club Number

Today Is

Full Name

Nick Name

Member Number

Omit For Guest

ADLT MBR REG COL MBR REG JOI MBR REG

Before Feb 6: Adult $40.00 COL $!5.00 JOI $1.00
After Feb 5: Adult $45.0 COL $20.00 JOI $15.00

ADLT LCH CHLD LCH ADLT DIN

Defore Feb 6: ADLT LCH $25.00 CHLD LCH $$10,00 ADLT DIN $40.00
After Feb 5: ADLT LCH $30.00 CHLD LCH $10.00 ADLT DIN $35.00

CHLD DIN ADLT BFT FST TMR

Before Feb 6: CHLD DIN $10.00 ADLT BFT $15.00
After Feb 5: CHLD DIN $10.00 ADLT BFT $ 20.00

Special Needs

Cost $

Enter total for
REG+LCH+DIN+BFT.

Register More?

Yes No

Full Name

Nick Name

Member Number

Omit For Guest

ADLT MBR REG COL MBR REG JOI MBR REG

Before Feb 6: Adult $40.00 COL $!5.00 JOI $1.00
After Feb 5: Adult $45.0 COL $20.00 JOI $15.00

ADLT LCH CHLD LCH ADLT DIN

Defore Feb 6: ADLT LCH $25.00 CHLD LCH $$10,00 ADLT DIN $40.00
After Feb 5: ADLT LCH $30.00 CHLD LCH $10.00 ADLT DIN $35.00

CHLD DIN ADLT BFT FST TMR

Before Feb 6: CHLD DIN $10.00 ADLT BFT $15.00
After Feb 5: CHLD DIN $10.00 ADLT BFT $ 20.00

Special Needs

Cost $

Enter total for
REG+LCH+DIN+BFT.

Register More?

Yes No

Full Name

Nick Name

Member Number

Omit For Guest

ADLT MBR REG COL MBR REG JOI MBR REG

Before Feb 6: Adult $40.00 COL $15.00 JOI $ 10.00
After Feb 5: Adult $45.00 COL $20.00 JOI $10.00

ADLT LCH CHLD LCH ADLT DIN

Defore Feb 6: ADLT LCH $25.00 CHLD LCH $$10,00 ADLT DIN $40.00
After Feb 5: ADLT LCH $30.00 CHLD LCH $10.00 ADLT DIN $35.00

CHLD DIN ADLT BFT FST TMR

Before Feb 6: CHLD DIN $10.00 ADLT BFT $15.00
After Feb 5: CHLD DIN $10.00 ADLT BFT $ 20.00

Special Needs

Cost $

Enter total for
REG+LCH+DIN+BFT.

Register More?

Yes No

Full Name

Nick Name

Member Number

Omit For Guest

ADLT MBR REG COL MBR REG JOI MBR REG

Before Feb 6: Adult $40.00 COL $15.00 JOI $ 10.00
After Feb 5: Adult $45.00 COL $20.00 JOI $10.00

ADLT LCH CHLD LCH ADLT DIN

Defore Feb 6: ADLT LCH $25.00 CHLD LCH $$10,00 ADLT DIN $40.00
After Feb 5: ADLT LCH $30.00 CHLD LCH $10.00 ADLT DIN $35.00

CHLD DIN ADLT BFT FST TMR

Before Feb 6: CHLD DIN $10.00 ADLT BFT $15.00
After Feb 5: CHLD DIN $10.00 ADLT BFT $ 20.00

Special Needs

Cost $

Enter total for
REG+LCH+DIN+BFT.

Registr More?

Yes No

Full Name

Nick Name

Member Number

Omit for guest.

ADLT MBR REG COL MBR REG JOI MBR REG

Before Feb 6: Adult $40.00 COL $15.00 JOI $ 10.00
After Feb 5: Adult $45.00 COL $20.00 JOI $10.00

ADLT LCH CHLD LCH ADLT DIN

Defore Feb 6: ADLT LCH $25.00 CHLD LCH $$10,00 ADLT DIN $40.00
After Feb 5: ADLT LCH $30.00 CHLD LCH $10.00 ADLT DIN $35.00

CHLD DIN ADLT BFT FST TMR

Before Feb 6: CHLD DIN $10.00 ADLT BFT $15.00
After Feb 5: CHLD DIN $10.00 ADLT BFT $ 20.00

Special Needs

Cost $

Enter total for
REG+LCH+DIN+BFT.

If childcare services are needed, send number and ages of children and time services are needed to
djmarino@verizon.net.
There will be no charge if pre-registered, otherwise cost will be $10.00 per hour per child.
If reserved and not utilized, charge to member will be $25.00.

Use the Submit button below or Mail printed form and check payable to:
South Carolina Optimist District 125 Creekwood Road Chapin, SC 29036-8804..
Pre-registrations also accepted via s-mail, e-mail, phone 803-312-4246 or fax 800-513-2321

Completed By

Your Email Address

Grand Total $

Total amount for all registrants.