PARENTS WITHOUT PARTNERS, INC.

40^TH INTERNATIONAL CONVENTION - JULY 7 - 11, 1999

REGISTRATION FORM

Registration Instructions:

Complete this registration form and send it with payment to JoAnn Reitenbach, P. O. Box 2703, St. Louis, MO 63116. Checks should be made payable to PWP International Convention. Admission to all events is by ticket only. All payments must be in US dollars. Early Bird Special deadline is March 31, 1999. Regular Early Registration deadline is May 15, Advance Registration deadline is June 11. After June 11, please register on-site. Full payment must accompany this form. Registration may be paid by credit card (Visa or Mastercard) or by check made payable to PWP International Convention.

Cancellations received in writing by June 11, 1999 will be refunded minus a $10 processing fee. After June 11 and before June 25, 1999, refunds will be considered on a case-by-case basis. NO refunds will be given after June 25, 1999.

All payments, advance or on-site, MUST be in US dollars. Badge replacement fee is $10.

Personal checks will NOT be accepted on-site. If paying on-site, please bring a cashiers check, money order, or credit card.

Registration Information

Membership #____________________________ Chapter Name & Number______________________________________

Last Name________________________First Name______________________Nickname for Badge___________________

Address_______________________________City________________________State_______Postal Code/Zip__________

Country____________Phone ___________________Fax _____________________E-Mail__________________________

Individual to call in an emergency:

Name___________________________________________Phone #_____________________________________________

If yes, position held______________________When__________

It is important to us that you enjoy the PWP convention. If, due to a disability, you have any special needs, accommodations or requirements, please let us know in the space provided and we will do our best to accommodate you.

Special needs:________________________________________________________________________________________

Please check the appropriate categories:

Full Registration: Includes all meetings, workshops, activities, dances, Awards Breakfast and Presidents Banquet & Ball. Does not include optional tours or events.

___$135 postmarked by March 31, 1999

___$150 postmarked by May 15, 1999

___$165 postmarked by June 11, 1999 and/or on-site

Individual Tickets:

You may purchase individual tickets to each event; however they are subject to availability.

____ ticket(s) @ $50 - Presidents Banquet & Ball (July 10)*

____ ticket(s) @ $25 - Awards Breakfast (July 8)*

____ tickets @ $25 - Wednesday Luncheon (July 7)*

*Included in Full Registration. Please note: A badge will only be issued for full package registrations.

Youth & Teen Program:

No registrations will be accepted after June 12, 1999. Please use one registration sheet per child.

Childs Name___________________________________Age______Birthdate______________Male/Female____________

Parents Name_______________________________________________________________________________________

Address _________________________________City_____________________________State/Zip___________________

Phone #________________________________

_______$120 - postmarked on or before May 15, 1999

_______$140 postmarked May 15 - June 12, 1999

Form of Payment: All payments must be in US dolllars.

Please check one: ____Visa ____Mastercard ____Check

Authorized amount to be charged: $______________

Credit Card #____________________________________________________ Exp. Date:__________________

Name as it appears on card____________________________________________________________________

Signature_________________________________________________________________________________

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