2017 Columbia Diversity Dinner Registration Form - Diversity Awareness Partnership

Name*

First Last

Company/Organization/School*

Address*

Street Address City State ZIP Code

Email*

Phone*

Are you a DAP Connect Member?*

Yes
No

Are you registering under a company's 2017 Diversity Dinner Sponsorship?*

Yes
No

If yes, which company?

General Dinner Ticket

Price: $60.00

Student Dinner Ticket

Price: $30.00

Table Sponsorship (Table of 8)

Price: $350.00

Please indicate any accommodations you require for this event:

Wheelchair Access
Sign Language Interpreter
Language Translator
Bringing Support Dog
Other (include in Questions/Comments section)

Dinner Selection*

Chicken
Vegetarian

Guest #1 Name

First Last

Guest #1 Email

Guest #1 Additional Accommodations

Wheelchair Access
Sign Language Interpreter
Language Translator
Bringing Support Dog
Other (include in Questions/Comments section)

Guest #1 Dinner Selection

Chicken
Vegetarian

Guest #2 Name

First Last

Guest #2 Email

Guest #2 Additional Accommodations

Wheelchair Access
Sign Language Interpreter
Language Translator
Bringing Support Dog
Other (include in Questions/Comments section)

Guest #2 Dinner Selection

Chicken
Vegetarian

Guest #3 Name

First Last

GUEST #3 Email

Guest #3 Additional Accommodations

Wheelchair Access
Sign Language Interpreter
Language Translator
Bringing Support Dog
Other (include in Questions/Comments section)

Guest #3 Dinner Selection

Chicken
Vegetarian

Total

$0.00

CANCELLATION POLICY
If you need to cancel your registration, 14 business days’ notice prior to the dinner is required for a refund of your registration cost. No refunds will be made after this date for any reason. Substitutions may be made at any time, without additional charges. Please contact Nikki McGruder at nmcgruder@dapstl.org or 573-817-4354 with cancellations or questions.