ABCC Association for Black Culture Centers 19th National Conference November 5 – 8, 2009 Registration Form Co-Sponsored By: The Cleveland State University Black Studies Program (216) 687-3655 Registrant Information (please print or type) Name Address City State ZIP Code Telephone/Cell No. Telephone (business) Fax E-Mail Conference Fees Registration Deadline: October 4, 2009 Early Registration – (General Non-Member): $ 200.00 Late Registration – (General Non-Member): $ 250.00 Early Registration – (Institutional Member*): $ 150.00 Late Registration – (Institutional Member*): $ 200.00 Early Registration – (College Student): $ 125.00 Late Registration – (College Student): $ 150.00 One Day Attendance – (Does not include meals): $ 100.00 Single Event Registration – (Does not include meals): $ 35.00 Optional: Treasurers of Jazz Concert Series Performance $ 30.00 (Performer-Vanessa Rubin and Jazz Heritage Orchestra Total Amount Sent:_______ Payment Information Refund Deadline: October 16, 2009 Refund Penalty – 50% refund if cancelled after: October 25, 2009 Preferred Method of Payment: Check ______ Credit Card _____ (Complete form below). Cash payments are only acceptable at the registration table at late registration fee rates. Pre-registration not required for cash payments. If you should have special needs such as mobility or dietary, please contact host site immediately. Credit Card Number Card Expiration Date Phone No. (Home) (Work) or (Cell) Credit Card Type Amount To Be Paid Date of Charge Name As Shown On Card Authorization Code (3-digit) Cardholder Mailing Address Student Name (If Applicable) Campus I.D. Number If Applicable) Authorized Signature Hotel Rates Hotel Reservation Deadline: October 4, 2009 Single Occupancy (King – Per night) $ 99.00 Double Occupancy (2 Queen Beds – Per night) $ 109.00 Hotel Address: Hilton Garden Inn – 1100 Carnegie Ave., Cleveland, Ohio 44115 – (216) 658-6400 Attendees are responsible for making individual hotel reservations. Please make checks payable to: Cleveland State University Black Studies Program Please return this form and direct any registration questions to: Oretha Barnett Coordinator of Administrative Services Cleveland State University Black Studies Program 2121 Euclid Ave, MC 137 Cleveland, Ohio 44115 Phone: (216) 687-3655/Email: firstname.lastname@example.org • Registration fees cover attendance at all sessions, conference-sponsored meals, registration packets and entertainment except Jazz Concert. Adult One Day Registration and Single Event Registration do not include meals or Jazz Concert. • Registration forms must be postmarked by October 4, 2009. • After October 4, 2009, participants must register at the late registration rate. * Attendees whose institution is a paid member of the Association for Black Culture Centers (ABCC).
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