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Event Sign-Up Form

2022 ICUB Convention and Conference

Before filling out the sign-up form below, you can review the event details by downloading the Event Packet using the buttons below. The first button is for the Microsoft Word version, the second is for the PDF version.

Download Event Info Word Document

Download Event Info PDF

Once you have read the Event Packet, fill out the form below to sign up. Registration is $20. Meals and raffle tickets are extra and denoted below:

2022 Convention Sign Up Form

Enter your contact information and make your meal selections below. Each registrant must fill out the form separately:

Enter Your First Name

Enter Your Last Name

Enter Your Email Address

Enter Your Phone Number

Street Address

City

State

Zip Code

WILL YOU BE ATTENDING IN PERSON OR OVER ZOOM?

I will be attending in person.

I will be attending over Zoom.

SELECT BREAKFAST OPTION ($15)

The Heartland: scrambled eggs and breakfast potatoes with sausage. Served with a fruit cup and choice of orange juice, coffee, tea, milk, or coffee.

Bistro Breakfast Sandwich: scrambled eggs, Applewood-smoked bacon, and white cheddar cheese on a brioche roll. Served with a fruit cup and choice of juice, milk, or coffee.

Sunrise Croissant: scrambled egg, Applewood-smoked bacon, sharp cheddar cheese on a butter croissant. Served with a fruit cup and choice of juice, milk or coffee.

SELECT LUNCH OPTION ($20)

Gourmet Cheeseburger: Applewood-smoked bacon, white cheddar cheese, lettuce, and tomato on a brioche bun. Served with a fruit cup, Seashore-Style fries and choice of water, tea, or coffee.

Veggie Wrap: vegetable wrap served with a fruit cup, pasta salad and choice of water, tea, or coffee.

Beef Stroganoff: braised beef tips and egg noodles topped with a cream sauce. Served with mashed potatoes, corn, dinner roll, and choice of water, tea, or coffee.

Smoked Turkey Wrap: smoked turkey and vegetable wrap served with a fruit cup, pasta salad, and choice of water, tea, or coffee.

SELECT BANQUET OPTION ($35)

Rosemary Pork Loin: roasted pork loin topped with a rosemary white sauce. Served with Yukon potatoes, salad, fresh vegetables, specialty bread, and choice of water, tea, lemonade, milk, or coffee.

Bacon Wrapped Sirloin: 8 oz. sirloin wrapped with Applewood-smoked bacon topped with a demi-glaze sauce. Served with baked potato, salad, fresh vegetables, specialty bread and choice of water, tea, lemonade, milk, or coffee.

Grilled Bruschetta Chicken: herb seared chicken breast topped with roasted cherry tomatoes, onion, basil and fresh garlic in wine sauce and a side of au gratin potatoes. Served with salad, fresh vegetables, specialty bread, and choice of water, tea, lemonade, milk, or coffee.

Stuffed Portabella Mushroom: a Portabella mushroom stuffed with roasted vegetables and topped with marinara, mozzarella, and Parmesan cheese. Served with a baked potato, salad, fresh vegetables, specialty bread, and choice of water, tea, lemonade, milk, or coffee.

NUMBER OF 50/50 RAFFLE TICKETS ($1 each or $5 for 6)

AMAZON FIRE TV RAFFLE ($5) FOR IN-PERSON ATTENDEES ONLY

ADDITIONAL DONATION AMOUNT (OPTIONAL)

PAY ELECTRONICALLY OR BY CHECK

I would like to pay electronically.

I would like to pay by check.

When you submit this form with the button below, you will receive a confirmation email. After that, if you elected electronic payment, you will receive another email with a link to make your payment. If you elected to pay by check, please send it to Jeana Mowery, Treasurer, 29965 185th St. Honey Creek, IA 51542. Make checks payable to the Iowa Council of the United Blind. Thank you!

Thank you for registering! You will receive an email confirmation shortly. If you do not see it within 15 minutes, please check your spam folder. Thank you! See you at the event!

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