ICGSA 39th ANNUAL CONFERENCE

REGISTRATION FORM

SUNDAY, FEB. 26, 2012

Plainfield High School

You may also register on-line for the conference at:

www.icgsa.org

ONE FORM PER PERSON

Name: ___________________________________________________________

Last First

Home Phone: (___)______________ Cell Phone: (___) _____________

Home Address: ____________________________City: ________________

State: ____________________Zip_________________

Home Email Address: ___________________________________________

School Email Address: __________________________________________

School: ______________________________ICGSA District: ___________

Sport/s: __________________________________________________________

PLEASE CHECK APPROPRIATE BLANK:

_____ $ 50 Advanced Registration, Current Member ($ 51 Advanced On-Line Registration Current Member)

_____ $ 85 Advanced Registration, Non-Member ($ 86 Advanced On-Line Registration Non-Member)

Note: This $35 fee activates your membership to ICGSA

A $20.00 Fee will be charged to those registering the day of the conference.

MAKE PAYMENT TO ICGSA AND SEND CONFERENCE REGISTRATION FORM:

Darlene Mathew

1635 600 W

Topeka, IN 46571

IN ORDER TO RECEIVE ALL GIVEAWAYS, REGISTRATION MUST BE

RECEIVED BY : February 17, 2012

Note: Only On-Line registration will be accepted after February 17, to insure that snail mail is received on time. On-Line registration will close on February 24, 2012.