ALPHA DELTA KAPPA DECEMBER 2010 - Gedung Kuning

“Excellence in Action”
Alpha Delta Kappa 2011 International Convention • Chicago, IL • July 13 - July 16, 2011
1. MEMBER INFORMATION
Please attach the peel and stick mailing label from your KAPPAN in the marked area.
If you are filling this area out by hand, your Member ID Number
may be found on your KAPPAN and Columns mailing labels.
Name
Member ID#
First Last
State/Province/Nation (S/P/N) & Chapter
Address
City S/P/N Zip/PC
First Name to Appear on Badge
Home Phone ( ) Work Phone ( )
Email Address
We’ve made it easy to register:
Mail your completed form with payment to
Alpha Delta Kappa’s bank lock box:
Alpha Delta Kappa
P.O. Box 879452
Kansas City, MO 64187-9452
2. EMERGENCY CONTACT (NOT Attending Convention)
( )
Name Phone
Or, if paying by MasterCard or VISA:
Fax your completed form to (816) 363-4010.
Our fax line is open 24 hours a day.
If faxing form, DO NOT mail a duplicate.
Register on-line after January 1 on the
Alpha Delta Kappa International website.
3. PLEASE TELL US . . .
Official Delegate Information (Voting Delegates and Alternates Only)
Check applicable designation:
Chapter Delegate (one per chapter) Chapter Alternate Delegate (one per chapter)
State/Provincial/National President S/P/N President-Elect
S/P/N Immediate Past President
2009-2011 International Chapter Past International Chapter (2007-2009 or 2005-2007)
Past International Executive Board Chairman Past International President
International Chairman of Committee/Scholarship Board
Special Designations: Please check special designations which apply to you:
Jetaneer: You are a Jetaneer if you have attended any seven International conventions, not necessarily consecutively.
First Timer: You are a First Timer when you attend your first International convention.
Golden Sister: You are a Golden Sister if you have been an Alpha Delta Kappa member for 50 or more years.
Sapphire Sister: You are a Sapphire Sister if you have been an Alpha Delta Kappa member for 35 or more years.
Silver Sister: You are a Silver Sister if you have been an Alpha Delta Kappa member for 25 or more years.
DoDos/All Timers: You are a DoDo if you were a province chairman. You are an All Timer if you have attended all
International Conventions and the 1955 National Convention.
All Sincers: You are an All Sincer if you have attended all International conventions since being initiated and have attended
at least three International conventions.
Volunteers:
I am neither a delegate nor alternate and wish to serve as assistant sergeant-at-arms.
I am a delegate or alternate but wish to serve as assistant sergeant-at-arms except Friday, July 15, when voting takes place.
As a musician, I wish to participate as follows:
Vocal Instrumental Both List instrument and/or choral part (e.g. soprano, alto):
4. SPECIAL NEEDS
Special seating requested for members with
wheelchairs and/or hearing or vision impairment
Vegetarian meals requested
Notify hotel of any special room needs: (800) 228-9290 or (312) 836-0100
5. MEMORIAL SERVICE
Reserve seats in the family
section for the family of:
See back for additional registration options. Excellence in Action in Leadership
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