Online Conference Registration Form

Printable Conference Information & Registration Form

 

PLEASE COMPLETE A SEPARATE FORM FOR EACH PARTICIPANT

General Information

Name

Title

Organization

Address
City       State      Zip  
Phone (h)     Phone(w)   

Fax:

 

E-mail:

 

Please complete the following: 

Parent Center Director/Representative (paid by SPAN)

Parent Center Additional Person - $100.00

Late registration fee - after May 15, 2009 - $125.00

Professionals/Others - $150.00

Late registration fee - after May 15, 2009 - $175.00

Hotel Accommodations:

Hotel rates are $139.00 plus tax, per night, per room, double occupancy.  All rooms are non-smoking, however, there are designated smoking areas on the premises.  SPAN will pay the cost of a shared double room for one parent center representative for 2 nights.  If you would like a single room you will be responsible for ½ the cost of that room ($64.50 plus tax).  Those paying their own way must still reserve rooms through SPAN for the conference rate.

 

Yes, I need hotel accommodations.             No, I will not need hotel accommodations.

I will need a room the nights of  June 15     June 16     June 17

I would like a single room and will be responsible for any additional costs.

I have a roommate preference, please room me with:

Name
Organization

I have no roommate preference, please assign me a roommate.

Special assistance needs: (physical accommodations, communication needs, or dietary restrictions)