NAACP: 11th ANNUAL LEADERSHIP 500 SUMMIT Rosen Shingle Creek Hotel Orlando, FL May 21-24, 2015 Registration Form Contact/ Registrant Information Last Name First Name Title/Position Organization Address I Address II City ( State ) ( Phone Zip Code ) Fax Email Special Needs Special Needs Request Please explain your special needs and required assistance as addressed by the Americans with Disabilities Act. ________________________________________________________________________________________ Special Meal Request Vegetarian Other ____________________________________________________________________________ Workshop Selection Please select your area(s) of interest: Civic Engagement/Voting Rights Criminal Justice Education Health NAACP: 11th ANNUAL LEADERSHIP 500 SUMMIT Registration Selections REGISTRATION FEES (Must be postmarked Before April 17, 2015) $300.00 SPOUSE/ GUEST REGISTRATION $300.00 (Please include Spouse/Guest Name) ___________________________________________ Youth $100.00 (Please include Youth's Name (Only 14 and under) _________________________________________________ Total Registration Fees $ ___________________ Payment Options OPTION I: CHECK/ MONEY ORDER PAYMENT Please make checks and money orders payable to: NAACP Mail the check or money order and Registration Form to: 2015 NAACP Leadership 500 Summit Attn: Tonya Banks 4805 Mt. Hope Drive Baltimore, MD 21215 OPTION II: CREDIT CARD PAYMENT Please choose the credit card type Visa Mastercard Discover American Express Credit Card Number 3-digit security code Expiration Date M M Y Y ________________________________________________________________________ Name (Please provide the name as it appears on the card.) Billing Address (if different from mailing address) __________________________________________________________________________________________ Address __________________________________________________________________________________________ City State Zip code ___________________________________________________________ ________________________ Authorized Signature ____________________________________________________________ Date ___________________________ IMPORTANT NOTE All Registrations and payment must be postmarked Before April 17, 2015. Request for cancellation must be received in writing by April 17, 2015. Cancellation by April 17, 2015 entitles the registrant to a refund of fees (less a $75.00 service fee). Refunds will be mailed within thirty (30) days following the conclusion of the Summit. We will not be able to refund registration fees for requests received after April 17, 2015.