Region 1 Annual Conference

Parent Centers:

Deepening Our Connections ≈ Empowering Families

 

 

Conference 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)

Late registration fee - after April 11, 2008 - $125.00

Late registration fee - after April 11, 2008 - $175.00

Hotel Accommodations:

Hotel rates are $149.00 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 up to 3 nights.  If you would like a single room you will be responsible for ½ the cost of that room ($74.50 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.

Hotel Arrival Date:             Departure Date: 

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)