2017 Annual Conference & Exposition Registration Form AWS
2017 Annual Conference & Exposition Registration Form A. Attendee Information PRINT OR TYPE (One Registrant per Form)
First Name: ___________________________________________________________________ Last Name: ________________________________
Title:____________________________________________________ Organization: ___________________________________________________ Address:________________________________________________________________________________________________________________
City/State/Zip:________________________________________________________________ Phone: ___________________________________ Email for confirmation: ______________________________________________ CC Email:_____________________________________________ Emergency Contact: __________________________________________________ Phone:_____________________________________________ Select all that Apply: ¨ First-time Attendee ¨ Volunteer to Moderate a Session ¨ ADA Reasonable Accommodation
¨ Dietary Restrictions ___________________________________________________________________________________________________
B. Registration
Pre-Conference Registration Monday, May 1, 2017
Evidence-Based Interventions for Maximizing Quality of Life & Reducing Unwanted Behavior Telehealth Opportunities in LeadingAge California Member Communities Your Nonprofit’s Story Begins with YOU
Full Conference Registration Monday, May 1 – Wednesday, May 3, 2017 Includes meals and conference programming only (precons & Monday lunch excluded)
Group Rate (5 or more from same organization)
¨ $495
Associate Member
¨ $699
Member Trustee
Resident/Student Government
Non Member
Early Bird Deadline 3/15/17
¨ $525
MEMBERS
¨ $150 ¨ $99 ¨ $99
¨ $595
NON-MEMBERS
¨ $300 ¨ $195 ¨ $195 Regular 4/13/17
¨ $625
¨ $799
¨ $425
¨ $525
¨ $225
¨ $225
¨ $250
¨ $250
¨ $995
¨ $1095
Daily Conference Registration Tuesday, May 2 or Wednesday, May 3, 2017 Includes breakfast and lunch only on day of registration
Early Bird Deadline 3/15/17
Tuesday
Wednesday
Tuesday
¨ $550
¨ $550
¨ $650
Member
¨ $375
Trustee
¨ $275
Associate Member Resident/Student Government
Non Member
¨ $160 ¨ $160
¨ $600
¨ $375 ¨ $275 ¨ $160 ¨ $160
¨ $600
¨ $475
¨ $300 ¨ $175 ¨ $175
¨ $700
Regular 4/13/17
Wednesday ¨ $475
¨ $650
¨ $300 ¨ $175 ¨ $175
¨ $700
C. Special Events and Extra Tickets
¨ Monday Lunch - $55 ¨ Tuesday Lunch and Exhibit Hall - $75 ¨ Tuesday Night Social Event - $90 ¨ Wednesday Business Meeting and Lunch - $55 ¨ Spouse/Guest Meal Ticket - $250. Guest Name: __________________________________________________________________________
(Guest registration includes Tuesday and Wednesday breakfast and lunch. (Co-workers or associates in the industry do not qualify.)
D. Payment
Total Section B: $___________ Total Section C: $_____________
0 GRAND TOTAL: $ ______________
Card #: _____________________________________________________________________Exp. Date:_________________ CSC: ___________
Cardholder’s Name: _____________________________________________________________________________________________________
Cardholder’s Signature: _________________________________________________________________________________________________ Mail or fax to: LeadingAge California, 1315 I Street, Suite 100, Sacramento, CA 95814, FAX: 916-254-5741. Registration Deadline: April 13, 2017. Onsite fees increase by $100.
First Name: ___________________________________________________________________ Last Name: ________________________________
Title:____________________________________________________ Organization: ___________________________________________________ Address:________________________________________________________________________________________________________________
City/State/Zip:________________________________________________________________ Phone: ___________________________________ Email for confirmation: ______________________________________________ CC Email:_____________________________________________ Emergency Contact: __________________________________________________ Phone:_____________________________________________ Select all that Apply: ¨ First-time Attendee ¨ Volunteer to Moderate a Session ¨ ADA Reasonable Accommodation
¨ Dietary Restrictions ___________________________________________________________________________________________________
B. Registration
Pre-Conference Registration Monday, May 1, 2017
Evidence-Based Interventions for Maximizing Quality of Life & Reducing Unwanted Behavior Telehealth Opportunities in LeadingAge California Member Communities Your Nonprofit’s Story Begins with YOU
Full Conference Registration Monday, May 1 – Wednesday, May 3, 2017 Includes meals and conference programming only (precons & Monday lunch excluded)
Group Rate (5 or more from same organization)
¨ $495
Associate Member
¨ $699
Member Trustee
Resident/Student Government
Non Member
Early Bird Deadline 3/15/17
¨ $525
MEMBERS
¨ $150 ¨ $99 ¨ $99
¨ $595
NON-MEMBERS
¨ $300 ¨ $195 ¨ $195 Regular 4/13/17
¨ $625
¨ $799
¨ $425
¨ $525
¨ $225
¨ $225
¨ $250
¨ $250
¨ $995
¨ $1095
Daily Conference Registration Tuesday, May 2 or Wednesday, May 3, 2017 Includes breakfast and lunch only on day of registration
Early Bird Deadline 3/15/17
Tuesday
Wednesday
Tuesday
¨ $550
¨ $550
¨ $650
Member
¨ $375
Trustee
¨ $275
Associate Member Resident/Student Government
Non Member
¨ $160 ¨ $160
¨ $600
¨ $375 ¨ $275 ¨ $160 ¨ $160
¨ $600
¨ $475
¨ $300 ¨ $175 ¨ $175
¨ $700
Regular 4/13/17
Wednesday ¨ $475
¨ $650
¨ $300 ¨ $175 ¨ $175
¨ $700
C. Special Events and Extra Tickets
¨ Monday Lunch - $55 ¨ Tuesday Lunch and Exhibit Hall - $75 ¨ Tuesday Night Social Event - $90 ¨ Wednesday Business Meeting and Lunch - $55 ¨ Spouse/Guest Meal Ticket - $250. Guest Name: __________________________________________________________________________
(Guest registration includes Tuesday and Wednesday breakfast and lunch. (Co-workers or associates in the industry do not qualify.)
D. Payment
Total Section B: $___________ Total Section C: $_____________
0 GRAND TOTAL: $ ______________
Card #: _____________________________________________________________________Exp. Date:_________________ CSC: ___________
Cardholder’s Name: _____________________________________________________________________________________________________
Cardholder’s Signature: _________________________________________________________________________________________________ Mail or fax to: LeadingAge California, 1315 I Street, Suite 100, Sacramento, CA 95814, FAX: 916-254-5741. Registration Deadline: April 13, 2017. Onsite fees increase by $100.
