 |
 |
|
||||||||||||
 |
 |
|||||||||||||
 |
 |
|||||||||||||
         
|
NHLBCC 2008 Registration Form This form must be completed by each attendee and returned with the initial deposit. Please print all information on this form. Last Name: ___________________________ First Name: _________________________________ Home Address: ____________________________________________________________________ City: _____________________________ State/Province: ________ Zip/Postal Code: ___________ Home Phone: ________________________ Work Phone: __________________________ Email: _______________________________________ Booster Club: ________________________ Name for I.D. Badge: ___________________________ Number of Previous Conventions: ______ Program Information - please circle one or more that refers to you: Include all of the above information Name Only Omit Address Omit telephone number Omit Email Age - circle one: under 21 over 21 Birthday: _______/_______ (month/day) Room Type: please circle one of three choices: Single $495.00 Double $395.00 Young Adult or Child between the ages of 5 - 17 staying in room with parent $175.00 Special Room Needs: _____________________________________________________________ Name: ____________________________________________ Club: _________________________ Name of Young Adult or Child: _____________________________________________ Name of Young Adult or Child: _____________________________________________ Do you need a roommate: Yes No Hotel Arrival Date: ___________ Hotel Departure Date: ____________ Method of arrival to Chicago: _______________ Airport, Airline and Flt. # ____________________
Friday Night Dinner - please circle choice: Chicken Wellington w/Wild Mushroom Ragout - chicken breast stuffed with mushroom duxelle wrapped in a flaky puff pastry, served on a bed of wild mushroom ragout. Prime Rib – hearty slice of prime rib topped with caramelized onions, served with chive potatoes, whipped horseradish sauce and natural au jus. Vegetable Wellington – vegetables wrapped in a flaky puff pastry. Saturday Night Dinner - please circle choice: Pork Loin - sliced roasted pork loin with mango relish served with chipotle mashed potatoes. Chicken Breast - grilled and marinated with fresh herbs served over saffron risotto. Eggplant Parmesan – hand braided eggplant topped with hearty marinara sauce on a bed of linguini.
Please list any food allergies or special dietary needs that we should be aware of: _______________ ___________________________________________________________________________________
Click here and "save as" to print word document registration form
Copyright NHLBCC 2007 |
|||||||||||||
|
|
||||||||||||||
