Glow Ball Fundraiser – Attendee Registration Name and Email * First Last Name * Last Name (and Credentials) Email Address * Email Address Organization/Practice Street Address * Street Address 2 City * State * Ohio Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Phone Number * Would you like to register as an individual (or multiple individuals) or as a foursome (or foursomes)? * Individual(s) Foursome(s) How many individuals would you like to register? ----- 1 - $75 2 - $150 3 - $225 4 - $300 5 - $375 6 - $450 7 - $525 8 - $600 9 - $675 10 - $750 How many foursomes would you like to register? ----- 1 - $275 2 - $550 3 - $825 4 - $1100 Please provide the name(s) of the other individual(s). Please provide the name(s) of the other individual(s). I would like to make an additional donation of ________ to the Ohio AAP Foundation. Total Due: If you are human, leave this field blank.