b'MIDWEST INSULATION CONTRACTORS ASSOCIATION ANNUAL CONVENTION REGISTRATION FORM The Hotel Alex JohnsonRapid City, SD June 16-20, 2024 Please print clearly or Register and Pay Securely Online at www.micainsulation.org. Use a separate form for each registration, and duplicate form as necessary. ___________________________________________________________________________________________________________________ COMPANY NAME ___________________________________________________________________________________________________________________ ATTENDEE NAMESPOUSE/GUEST NAME ___________________________________________________________________________________________________________________ CHILDREN NAME(S) if Registered ___________________________________________________________________________________________________________________ BILLING ADDRESSCITY STATEZIP ___________________________________________________________________________________________________________________ E-MAILOFFICE PHONECELL PHONEFirst Time Attendee YesNoCONFERENCE REGISTRATION:NumberTotal First Attendee from MICA Member Firm - $825.00 _______ $__________ Each additional Attendee from the Same Member Firm - $800.00_______ $__________ First Couple from MICA Member Firm (Member & Spouse/Guest) - $1,650.00 _______ $__________ Each additional Couple from the Same Member Firm - $1,600.00_______ $__________ Non-Member Attendees - $900.00 Per Person_______ $__________ Children Under 18 - $0.00 No Charge (Welcome Reception and Farewell Breakfast Only)_______ $__________ Member/Spouse Opening Breakfast: I/We (will) (will not) attend the Opening Session Breakfast on Tuesday, June 18 th .The Number Attending is_______ Gala Dinner/Dance: I/We (will) (will not) attend the Gala Dinner/Dance on Wednesday Evening, June 19 th .The Number Attending is_______ Farewell Breakfast/Brunch: I/We (will) (will not) attend the Farewell Breakfast on Thursday Morning, June 20 th .The Number Attending is_______ ADDITIONAL ACTIVITIES: 26th Annual Mick Van Horn Memorial Scramble Golf Tournament: Golf Tournament Registration - $180.00Name: _______________________________ Handicap __________ $__________Golf Club Rental - $75.00Please Specify: (Men/Womens Clubs) (Left/Right-Handed)$__________ Golf Tournament Registration - $180.00Name: _______________________________ Handicap __________ $__________ Golf Club Rental - $75.00Please Specify: (Men/Womens Clubs) (Left/Right-Handed)$__________ Golf Registration Fee includes lunch, 18 holes of golf, shared golf cart, complimentary use of practice and range area, and prizes.Slacks or Bermuda length shorts, collared shirt and non-metal spiked golf or tennis shoes are required.Cut-offs and T-shirts are prohibited anywhere on the premises. Tuesday Spouse/Guest Outing: Activity TBA$0.00 Free of Charge Name: _________________________________$0.00 Free of Charge Name: _________________________________$0.00 Free of Charge Name: _________________________________$0.00 Free of Charge Name: _________________________________'