Blue Knights ® Southern Regional Conference
                             April 19-21, 2012, Space Coast Florida Chapter XII
                                                    Cocoa Beach, Florida

Members Name: ___________________________________________________Age:_____________
Address: __________________________________________ State: _________ Zip: _____________
State & Chapter: __________________________ Phone Number  ____________________________
Email Address___________________________ Distance Traveled by MC to Conference:__________
Emergency Phone Number  _____________________ Contact Person: _________________________

Spouse/ Significant Other/Guest: ______________________________________Age:________
Address: __________________________________________ State: ________ Zip: ____________
Emergency Phone Number ____________________Contact Person:____________________________

Conference Registration
$ 70.00 Per Person / $140.00 per couple before March 09, 2012.  Early Registrations receive free Thin Blue Line Lanyard with Conference ID and Free Conference Pin.

Number Attending: ________@ $70.00 each.

Early Registration T-Shirt Color Choices - Pink - Light Blue - Yellow 
Conference T-Shirt: #_______@ $12.00 each in sizes S-XL - Color_______ Size ______
Conference T-Shirt: #_______@ $15.00 each in sizes 2X-4X - Color______ Size______
Shirts sold at Conference will be Light Blue Only.

Dinner Choices: One for each attending:  Chicken:____ Fish:___ Pork:____ Beef:____
(*For Beef, please add $5.00 per person to total enclosed, below)

EARLY REGISTRATION (encouraged) :
Best Western Ocean Beach Hotel & Suites
5500 North Atlantic Avenue
Cocoa Beach, FL  32931
Phone: (321)784-2550, Ext 366 or 377 Ask for Blue Knights Rate $69.99 Per Night for standard rooms.
$99.00 for Suites. $109.00 for Ocean Front.  These rates include a hot breakfast bar. Rates are available for early arrival and late departure.  Bring the family and spend the week at the beach.

Will your Chapter need a Sales Table? ______  
Total Enclosed: $ _____________* Payable to Blue Knights® Florida XII, 928 Fir St., Barefoot Bay, FL 32976

Conference Fees Cover Fridays Barbeque - Saturday Night Banquet *except as indicated above - Police Escorted Ride/Parade Tour & Photo Op at Kennedy Space Center - Entrance to the American Police Hall of Fame & Museum - Unlimited Soft drinks - Bottled Water - Beer on tap, and Door Prizes.

DIRECTIONS:  I-95 to Exit 201 (SR 520) East to SR A1A (North Atlantic Ave) North to Best Western on the right.

Questions, contact: President,Jay Martin at hdcop104@aol.com <mailto:hdcop104@aol.com> 321-508-4577 
Secretary, Gene Snyder at blueknightsfl12@gmail.com <mailto:blueknightsfl12@gmail.com> or 321-338-6630.