Full Name:
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Address line 1:
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Address line 2:
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City:
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State:
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Zip/Postal Code:
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Phone (Home):
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Phone (Alternate):
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Email Address:
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Format Preference:
Large Print
Braille
Cassette
Email
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Mobility Impairment:
Yes
No
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Guide Dog User:
Yes
No
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First Time Attendee:
Yes
No
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Late check out on Sunday:
Yes
No
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Pre-registration:
Pre-registration $10.00.
After October 7 $12.00
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Friday Schedule: |
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Please indicate from the list below those activities and preferences of your choice.
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Friday Morning tour $20.00
Yes
No
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Hershey's Chocolate World-Lunch Choice includes:
choice of sandwich and either soup or salad.
Choose one of the following:
Ham & Cheese
Chicken Salad
Egg Salad
Choose one side dish:
Chicken Noodle
Chili
Broccoli Cheese
Salad
Chips and Beverage included.
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Will you play Audio Darts:
Yes
No
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Friday Workshops:
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Leadership Workshop-presented by PCB Long Range Planning Committee:
Yes
No
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Braille Workshop-presented by PCB Braille Committee:
Yes
No
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First Timer's event: (First Timers ONLY)
Yes
No
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Saturday Schedule: |
Saturday President's Lunch:
Roasted Vegetable Wrap$16.75
Ham & Cheese Wrap$16.75
Turkey Croissant$16.75
Attending, but not eating.
Not Attending.
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All box lunches include potato chips, fresh fruit, cookie, and bottled water.
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Saturday Banquet:
House Signature Steak $36.00
Penne Rustica $26.50
Not attending
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I will participate in the Post Banquet entertainment stories "Sharing Our Stories.":
Yes
No
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Sunday Schedule: |
Sunday Breakfast Business Meeting:
Sunday Breakfast Business Meeting $14.50
No
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50/50 room rate fund tickets $5.00 per ticket, Number of Tickets:
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PCB Donor:
Patron $5.00
Contributor $10.00
Benefactor: $25.00
Not donating
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Type of Payment:
PayPal Or Credit Card
Cash
Money Order
Check
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