School Membership and
Conference Delegate Registration

New York City, NY

School Name:

_________________________________

 School Advisor:

_________________________________

School Address:

_________________________________

City:

_________________________________

State:

__________________    Zip: ______________

Phone:

___________________  Fax: ______________

 Email:

_________________________________

Co-op Buyer:

_________________________________

I want to be added to the APCA List Serve: __ Yes    __ No

Student Activities Board Members

 Position

____________________________________

__________________________

____________________________________

__________________________

____________________________________

__________________________

____________________________________

__________________________

____________________________________

__________________________

% of Budget spent on:

Comedy: ____%

Lectures: ____%

Movies: ____%

 

Music: ____%

Novelties: ____%

Other: ____%

Student Population

Demographics

   __ BELOW 3,000

Public:__  Private:__ 

   __ 3,000 – 5000

Commuter: __ Religious:____

   __ 5,000 - 10,000

4-year: __ 2-year: __

   __ 10,000 -15,000

Tech/Trade: __

   __ 15,000 - UP

Activities Budget: $ __________

Student Activities Journal Subscriptions should be mailed to:
(3 subscriptions per membership, extra subscriptions $29.95 per year)

Name:

________________________________

Address:

________________________________

City:

________________ State: ________   Zip: ________

Name:

________________________________

Address:

________________________________

City:

________________ State: ________ Zip: ________

Name:

________________________________

Address:

________________________________

City:

________________ State: ________ Zip: ________

Names of Delegates Attending APCA Conference/Workshop (list additional delegates separately):

Delegate 1:_______________________

 

Delegate 5:_______________________

Delegate 2:_______________________

 

Delegate 6:_______________________

Delegate 3:_______________________

 

Delegate 7:_______________________

Delegate 4:_______________________

 

Delegate 8:_______________________

Delegate Fee Schedule
Can not be employee or student representing interests of attending organization.
REVIEW CAREFULLY TO AVOID MISCALCULATION OF FEES!

Prior to 6/30/12

Member

Non-Member

Day Pass (member)

Day Pass (non-member)

1-5 delegates

$349 / delegate

$389 / delegate

$229 / delegate

$269 / delegate

6 + delegates

$329 / delegate

$369 / delegate

$229 / delegate

$269 / delegate

After 6/30/12

Member

Non-Member

Day Pass (member)

Day Pass (non-member)

1-5 delegates

$389 / delegate

$429 / delegate

$269 / delegate

$289 / delegate

6 + delegates

$369 / delegate

$399 / delegate

$269 / delegate

$289 / delegate

 

 

 

 

 

Sardis Keynote Luncheon (Open to students & advisors) $39.95

Delegate fees enclosed

$______

Spousal fees enclosed for __ number of spouses/domestic partners @ $169 ea.

$______

____  Institutional membership fees enclosed ($299 per campus)
_____ We are an APCA Member (membership fees already paid through July 1, 2013)
Schools registering delegates must be APCA members in good standing or pay nonmember prices.

$______

Total # of Shirts: ______
Indicate # per size: ______ Med   ______ Lg  ______ XL  ______ XXL   ______ XXXL

$______

TOTAL FEES ENCLOSED or AUTHORIZED TO BE CHARGED
The APCA FEI Number is 650551461

$

We will require _____ vegetarian meals
(If unknown, please contact us at (800) 681-5031 when number is determined.)

Credit Card Orders:
__VISA   __MasterCard  __American Express
Card Number: ________________   Exp. Date: ________
Name on Card: ________________________ CVV2 #:____ (3 digit # on right back or card)
 
Signature: __________________________________ Date:___/___/___

Billing Information:
Billing Address: ________________________________________
City, State: _____________________________, _________  Zip: ___________________

Signature of Advisor: _________________________ Date:___/___/___
Please Print Advisorīs Name Here: ________________________________
Conference Cooperative Buyer (please print): ______________________________
I have read and agree to abide by the APCA registration and membership policies
as outlined on this web site.

FTE Card Applicants:
   NOTE: FTE discounts are only applicable to onsite purchases made at conference.
   # of Full Time Enrolled students: ____________
     Applicable discount:  3%__    5% __   7% __

Faculty confirming full time enrollment of school: ______________________________
Phone number of school registrar's office: ______________________________

Mail this form with You may fax this form with Credit Card information to 865-908-7104 or mail check payable to APCA to:

APCA, P.O. Box 4340, Sevierville, TN 37862
(800) 681-5031 www.apca.com

Lodging Information Click Here

Refunds: Delegate fees are nonrefundable, but a $75 credit per canceled delegate towards your choice of another APCA conference is allowable in event of cancellations (good for one year from ending date of canceled conference).