Chapter/Organization Registration Form
Alpha Phi Alpha Fraternity, Inc., Eastern Region
Leadership Development Institute
LDI ERC   LDI South   LDI North
LDI South
LDI ERC
LDI North
Contact Person
Preferred Phone
Alternate Phone
Street Address
City
State
Zip Code
Email Address
Chapter/Organization Information
Chapter/Organization Name
Chapter/Organization President
Chapter/Organization
Street Address
City
State
Zip Code
Registrant Information
Reminder -- There is no registration fee for LDI (ERC)
@
Alpha Ambassador
$400.00    =
Qty
Mentor/Chaperone
@
$400.00   =
Qty
Total Amount Due/Paid    =
Payment Method
Check/Money Order #
Chapter/Organization Check (please include Check #)
Money Order (please include money order number)
--NOTE--
FOR LDI SOUTH
All checks or money orders ($400
per Ambasaador/Chaperone
) are
made payable to:
Alpha Scholarship Endowment Fund of IUL
and sent to:
Anthony Cheatham
811 East Randolph Road
Silver Spring, MD 29094
--NOTE--
FOR LDI NORTH
All checks or money orders ($400
per Ambassador/Chaperone)
are
made payable to:
ETL Education Foundation
and sent to:
Steven B. Skinner (LDI)
116-19 228th Street
Cambria Heights, NY 11411
Participant Information
Please enter some basic participant information below.  Please note that
Chaperones/Mentors and Ambassadors must submit separate online registrations.
Upon receipt of this form, LDI personnel shall contact each Ambassador or
Mentor/Chaperone and provide them a link to complete the registration process.  
You can enter up to 4 Ambassadors and 2 Mentors on this form.
________________________________________________________________________________
Ambassador #1
Last Name
First Name
Street Address
City
State
Zip Code
Ambassador
Email Address
Parent Email
________________________________________________________________________________
Ambassador #2
Last Name
First Name
Street Address
City
State
Zip Code
Parent
Email
Ambassador
Email
________________________________________________________________________________
Ambassador #3
Last Name
First Name
Street Address
City
State
Zip Code
Parent
Email
Ambassador
Email
________________________________________________________________________________
Ambassador #4
Last Name
First Name
Street Address
City
State
Zip Code
Parent
Email
Email Address
________________________________________________________________________________
Mentor/Chaperone #1
Last Name
First Name
Street Address
City
State
Zip Code
Email Address
________________________________________________________________________________
Mentor/Chaperone #2
Last Name
First Name
Street Address
City
State
Zip Code
Email Address
Complete all appropriate fields and press the Submit Form button at the bottom of the screen.