2019 Dinner - Individual Registration - 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 2019 Diversity Dinner Sponsorship?*

Yes
No

If yes, which company?

VIP Reception with Dr. Rohini Anand

Price: $200.00

Includes cocktails and hors d'oeuvres.

General Dinner Ticket

Price: $150.00

Student Dinner Ticket

Price: $65.00

Ten tickets (Entire table)

Price: $1,250.00

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 will be accepted until November 5, without additional charges. Please contact Tina Mahtani at tmahtani@dapinclusive.org or 314-246-3146 with cancellations or questions.

Diversity Awareness Partnership

2019 Dinner – Individual Registration

2019 Diversity Dinner Registration Form