ArrowHEADS Registration Form

Name: Lodge:

Leadership Position (If any):

Address:

City: State: Zip:

Email: Phone:

Birth Date: Sex (M or F):

Special Dietary Needs:

Special Handicap Needs:

Step 1:

Choose a Track (Please check ONE preference):

q LMT --- Lodge Management Track

q IAT --- Indian Affairs Track

q CMT --- Chapter Management Track

q TTT --- Train The Trainer Track

q PLD --- Personal Leadership Development Track

Step 2:

Please list electives in order of preference from 1 to 4:

Elective Choice # 1:

Elective Choice # 2:

Elective Choice # 3:

Elective Choice # 4:

Step 3:

If you would like to Pre-Order a Seminar T-Shirt, please indicate the Size and Quantity desired below:

Quantity X $12.00 = Total

Circle Size: Small Medium Large XL XXL XXXL (Note: These are Men’s Sizes)

A Seminar T-Shirt is NOT mandatory to attend!

Step 4:

Mail this form, along with the Medical Form filled out completely and a check in the amount of $50.00 by February 1, 2007. Please make checks payable to the Old North State Council. Please mail this form and your check to: Old North State Council, ArrowHEADS, PO Box 29046, Greensboro NC 27429-9046, Attn: Ted Williams

Please indicate the Total Amount:

Course Fee of $50.00 + Optional T-Shirt(s) $_______ = $_______