2018 Registration Form
2018 REGISTRATION FORM DFW CMSA SPRING CONFERENCE APRIL 20-21-2018 Hilton Arlington Hotel, Arlington, Texas “Case Management: Constructing Better Outcomes” NAME: ________________________________________________CREDENTIALS: ________________ NICKNAME FOR BADGE: ______________________________________________________________ ADDRESS: ____________________________________________________________________________ CITY: __________________________________________STATE: _____________ZIP: _____________ TELEPHONE: __________________________________________ COMPANY/FACILITY: ________________________________________________________________ EMAIL ADDRESS: ____________________________________________________________________ (FOR CONFIRMATION OF REGISTRATION) _____PLEASE CHECK IF YOU REQUIRE SPECIAL ASSISTANCE (PLEASE DESCRIBE BELOW): ______________________________________________________________________ APRIL 20-21-2018 REGISTRATION FEES: CONFERENCE RATE BEFORE 4/2/2018 CMSA MEMBER NON MEMBER DAILY RATE CMSA MEMBER DAILY RATE NON MEMBER
CONFERENCE RATE AFTER 4/2/2018
TOTAL
$199 $279
$299 $329
$_________ $_________
$100
$150
$_________
$189
$209
$_________
TOTAL AMOUNT ENCLOSED CHECK WHICH DAY (S) YOU ARE ATTENDING: __________APRIL 20th
$_________ _________APRIL 21st
Payment for $_______________ enclosed. Please make checks or money order payable to: DFW CMSA Charge my Credit Card: MASTERCARD _______VISA _______AMEX _______DISCOVER_______ Card Number: _______________________ Expiration Date: ______________ Security Code: _______ Zip Code for Billing Address of Credit Card: ______________________________ Name as it appears on card: ____________________________________________ Signature: __________________________________________________________ Will You Be Attending the “Member Only Breakfast” on Saturday, April 21, 2018 YES______
NO_________
To register by mail, make checks/money orders payable to: DFW CMSA Mail to: DFW CMSA, P. O. Box 763877, Dallas, Texas 75376
NO REFUNDS AFTER APRIL 2nd .Cancellations received in writing before APRIL 2, 2018 will receive a refund less a $50 administrative charge. For more info call 214/282-7832 or email [email protected] Hotel Information: The conference hotel is the Hilton Arlington Hotel located at 2401 East Lamar Boulevard, Arlington, Texas 760006. Make your reservation no later than 5:00 PM on March 29, 2018 to receive the discounted DFW CMSA rate of $149.00 single/double rate plus tax. Make reservations by telephoning 817/640-3322 and identifying yourself as part of “Case Management Society of America”.
CONFERENCE RATE AFTER 4/2/2018
TOTAL
$199 $279
$299 $329
$_________ $_________
$100
$150
$_________
$189
$209
$_________
TOTAL AMOUNT ENCLOSED CHECK WHICH DAY (S) YOU ARE ATTENDING: __________APRIL 20th
$_________ _________APRIL 21st
Payment for $_______________ enclosed. Please make checks or money order payable to: DFW CMSA Charge my Credit Card: MASTERCARD _______VISA _______AMEX _______DISCOVER_______ Card Number: _______________________ Expiration Date: ______________ Security Code: _______ Zip Code for Billing Address of Credit Card: ______________________________ Name as it appears on card: ____________________________________________ Signature: __________________________________________________________ Will You Be Attending the “Member Only Breakfast” on Saturday, April 21, 2018 YES______
NO_________
To register by mail, make checks/money orders payable to: DFW CMSA Mail to: DFW CMSA, P. O. Box 763877, Dallas, Texas 75376
NO REFUNDS AFTER APRIL 2nd .Cancellations received in writing before APRIL 2, 2018 will receive a refund less a $50 administrative charge. For more info call 214/282-7832 or email [email protected] Hotel Information: The conference hotel is the Hilton Arlington Hotel located at 2401 East Lamar Boulevard, Arlington, Texas 760006. Make your reservation no later than 5:00 PM on March 29, 2018 to receive the discounted DFW CMSA rate of $149.00 single/double rate plus tax. Make reservations by telephoning 817/640-3322 and identifying yourself as part of “Case Management Society of America”.
