.

Company/
Organization
Contact Name
Youth    Adult   
If Youth, Chaperone Name
Address
City
State
Zip
Phone
Fax
Email
Website

Registrant Name: (As you would like it to appear on the name badge)

Fee Schedule: Youth Adult Chaperone
Early Full Registration
(before Sept. 31)		 $395 $495 $295
Full Registration $495 $595 $395
2 Day Registration $295 $395 $195
1 Day Registration $125 $195 $100

Registration Type: Youth    Adult    Chaperone

If registering as a chaperone: Only 1 adult allowed at chaperon cost per 4 registered youth. If registering as a chaperon, please list the youth who will be attending with you.

1.   2.
3.   4.

Registration Total Amount:

Guests: I would like to invite a guest to attend one or more of the Special Events as indicated below, and have included payment in addition to my registration cost.

  Youth Adult
Welcome Reception & Health & Hip-Hop Expo Opening $15 Qty $20 Qty
Lunch & Hip-Hop Fashion Show $40 Qty $55 Qty
Celebrity Sports Event $45 Qty $60 Qty
Keeping It Real Lunch $40 Qty $55 Qty
YPCI Awards Banquet $45 Qty $60 Qty
Sunday Breakfast $25 Qty $35 Qty

Describe any physical or dietary restrictions.

Guest Tickets Total Amount:

Total Amount: (Registration + Guest Tickets)


Payment:
Credit Card     Check/Money Order

Checks must be made in US funds drawn on US banks. Make checks payable to YPCI and Direct Mail this form and payment to: YPCI Summit Manager, P.O. Box 265, Clinton, MD 20735.


Credit Card:
Type of Credit Card:
Name (As It Appears on Credit Card):
Credit Card Number:
Expiration Date:
Amount:


Submit Via:

Mail:
Print out form. Enclose check (if necessary). Send to:

Summit Manager
YPCI
P.O. Box 265
Clinton, MD 20735

Fax:
Print out form. Mail check (if necessary) Fax to:

(301) 877-9581

Email:
Click button below to submit. Mail check (if necessary).

For registration inquiries please Call Adriane Alfred at 301-877-3824.

 

Cancellation & Refund Policy: All cancellations must be in writing. Cancellations received before September 30th will receive a 50% refund. Cancellations received after September 30 will not be refunded. Participation substitution charge is $150.00. All refunds will be processed within 60 days from the conclusion of the conference. Please forward refund requests to YPCI Summit Manager, P.O. Box 265, Clinton, MD 20735. .

PLEASE COMPLETE ONE FORM FOR EACH REGISTRANT.

Click here to go back to website