12/5/2016

2016FLCRegistrationFormWomack,Melissa

2016 FLC Registration Form

Georgia FBLA <noreply@wufoo.com>
Mon 10/17/2016 8:15 AM
To: Womack,

Melissa <melissa.womack@bartow.k12.ga.us>;

Your FLC Registration has been received. If you have more than 8 members attending, please complete an additional

registration forms as needed. If you need to make changes to your registration, please use the substitution/change form or
the registration cancellation request form (links in the LiveBinder). There will not be a charge for changes made through
October 14. After October 14, these changes will incur a $10 per change fee.
Once you have finalized your registration without making additional changes, you can request an official invoice for this
conference by sending an email conference@georgiafbla.org. Please allow up to 72 hours for this invoice to be emailed to you.
Mail complete payment to Georgia FBLA, 3316-A South Cobb Drive, Suite #229, Smyrna, GA 30080. Payment must be
RECEIVED no later than October 24 to avoid late payment penalties.
To pay for FLC Registration Fees by credit card, go to https://georgiafbla.wufoo.com/forms/online-credit-card-paymentform/. Do not forget to add the 3.5% processing fee to the amount due if you choose to pay by credit card.
Membership dues for members registered which have not been received by the registration date must be received in the
national office no later than October 31 for this member to be eligible to participate in the Fall Leadership Conference.

2016 FLC Registration Form

Chapter Number *

1904

School Name *

Adairsville High School

Primary Adviser Name *

Melissa Womack

Adviser Email Address (confirmation will be

sent here) *

melissa.womack@bartow.k12.ga.us

Select the Opening Session Your Chapter Will

Attend *

Session A: 7:00 pm - 8:15 pm

Name of Adviser #1

Melissa Womack

T-shirt Size for Adviser #1

Large

Registration Fee for Adviser #1

$50.00

Membership ID Number for Member #1

2516789

Name of Member #1

Paige Kerr

T-shirt Size for Member #1

Small

Leadership Track First Choice for Member #1

Business Management (limit 2)

(Required)
https://outlook.office.com/owa/?viewmodel=ReadMessageItem&ItemID=AAMkAGYxZTMzOTQ0LTZmZGItNDM5NC1hODNmLWFjYWQwOGU1YzMxMgB

1/3

12/5/2016

2016FLCRegistrationFormWomack,Melissa

(Required)
Leadership Track Second Choice for Member
#1 (Required)

Professionalism & Etiquette

Registration Fee for Member #1

$50.00

Membership ID Number for Member #2

1965469

Name of Member #2

Karen Perez

T-shirt Size for Member #2

Medium

Leadership Track First Choice for Member #2

(Required)

Advanced Officership

Leadership Track Second Choice for Member

#2 (Required)

Professionalism & Etiquette

Registration Fee for Member #2

$50.00

Membership ID Number for Member #3

2516807

Name of Member #3

Caleb Mealer

T-shirt Size for Member #3

Large

Leadership Track First Choice for Member #3

(Required)

FBLA Officership

Leadership Track Second Choice for Member

#3 (Required

Entrepreneurship (limit 2)

Registration Fee for Member #3

$50.00

Membership ID Number for Member #4

2541490

Name of Member #4

Ella Hendrix

T-shirt Size for Member #4

Small

Leadership Track First Choice for Member #4

(Required)

FBLA Officership

Leadership Track Second Choice for Member

#4 (Required)

Community Service

Registration Fee for Member #4

$50.00

Membership ID Number for Member #5

1969926

Name of Member #5

Allison Storm

T-shirt Size for Member #5

Large

Leadership Track First Choice for Member #5

(Required)

Advanced Officership

Leadership Track Second Choice for Member

#5 (Required)

Professionalism & Etiquette

Registration Fee for Member #5

$50.00

https://outlook.office.com/owa/?viewmodel=ReadMessageItem&ItemID=AAMkAGYxZTMzOTQ0LTZmZGItNDM5NC1hODNmLWFjYWQwOGU1YzMxMgB

2/3

12/5/2016

2016FLCRegistrationFormWomack,Melissa

Membership ID Number for Member #6

2516791

Name of Member #6

Daniel Sullivan

T-shirt Size for Member #6

Medium

Leadership Track First Choice for Member #6

(Required)

FBLA Officership

Leadership Track Second Choice for Member

#6 (Required)

Entrepreneurship (limit 2)

Registration Fee for Member #6

$50.00

A. Number of Advisers Registered *

B. Number of Members Registered *

C. Number of Chaperones Registered

D. Total Number of Individuals Registered

(A+B+C) *

E. Number of 2XL, 3XL, and 4XL t-shirts

ordered

F. Number of Chick-fil-A Breakfasts ordered

G. Number of Monopoly Teams (1-3

members).

H. Total Registration (Line D x $50) *

$350.00

I. T-shirt Surcharge (Line E x $5)

$0.00

J. Chick-fil-A Breakfast Fees (Line F x $5)

$0.00

K. Monopoly Tournament Fees (Line G x $12)

$24.00

L. Total Amount Due (Line H + Line I + Line J

+ Line K) *

$374.00

https://outlook.office.com/owa/?viewmodel=ReadMessageItem&ItemID=AAMkAGYxZTMzOTQ0LTZmZGItNDM5NC1hODNmLWFjYWQwOGU1YzMxMgB

3/3