Chapter/Organization Registration Form
Alpha Phi Alpha Fraternity, Inc., Eastern Region

2021 Leadership Development Institute
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
@
Alpha Ambassador
$50.00    =
Qty
Total Amount Due/Paid    =
--NOTE--
Within 24 hours of receipt of this form, an invoice for immediate payment will
be sent to the above designated contact email address.  The listed
Ambassadors and parents will be contacted by email and asked to complete
the Ambassador Registration form.  We will copy you on all correspondence
sent to your sponsored Ambassadors.
Participant Information
Please enter some basic participant information below.    You can enter up to
6 Ambassadors on this form.  If you are seeking to sponsor more than 6
Ambassadors, please submit an additional 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
________________________________________________________________________________
Ambassador #5
Last Name
First Name
Street Address
City
State
Zip Code
Parent
Email
Email Address
________________________________________________________________________________
Ambassador #6
Last Name
First Name
Street Address
City
State
Zip Code
Parent
Email
Email Address
Complete all appropriate fields and press the Submit Form button at the bottom of the screen.