Spring 2010 Conference Registration form by HC121105132134

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									                                               Association on

     AHEAD in VA                               Higher Education
                                               And Disability
                                               in Virginia
              www.aheadinva.org
 _______________________________________________________________
 "Staying AHEAD of the Game”                    Elston Inn & Conference Center
 Spring 2010 Conference                                    Sweet Briar, Virginia
 March 25 & 26, 2010                                        www.elstoninn.com

Section 1: Personal Information:
Last Name: ________________________ First Name: __________________ MI: ________

Title: ________________________________________________________________________

Institution/ Organization: ________________________________________________________

Address 1: ___________________________________________________________________

Address 2: ___________________________________________________________________

City, State, Zip: _______________________________________________________________

Phone: (_____)-________________________        Fax: (_____)-________________________

TTY: (_____)-______________________     Website: _________________________________

Email: _________________________@____________________________________________

Section 2: Conference Registration             Total fee enclosed $_________
      Two-Day Conference Fee                          One-Day Conference Fee
      (includes lunch both days):                     (Includes lunch):

_____ $225 – Member                     _____ $150 – Member                 Select Day:

_____ $250 – Non-Member                 _____ $175 – Non-Member           _____ March 25

_____ $100 – Full-time Student          _____ $50 – Full-time Student     _____ March 26

      _____ $25.00 – 20th Anniversary Gala Banquet, Thursday evening, March 25h
            (this meal/event is not included in conference registration fee)

      _____ $13.50 – .9 Continuing Education Unit (CEU) for two day conference attendance
            (offered through Patrick Henry Community College)

If you are a member of AHEAD in Virginia for 2009-2010, you can register at the
Member rate – not sure if you are a current member? Check out the membership listing at
www.aheadinva.org. Not a member but want to join to get the member rate? The Membership
Application is at www.aheadinva.org.
Section 3: Approved Forms of Payment:

Please note - All registrations must be submitted with an approved form of
payment.

AHEAD in Virginia now accepts payment in the form of Visa and MasterCard. We do not accept
purchase orders as payment for conference registrations and memberships. We apologize for
any inconvenience this may cause. If you have questions, please contact Nancy Beach,
Treasurer, at information listed below.

_______ Personal Check        _______ Institutional Check     _______ Money Order

_______ Visa                  _______ MasterCard

_____________________________________________________
Name on card

__________________________________              __________________
Account number                                  Expiration date

Make Payment to:           AHEAD in Virginia

Send Payment to:           Nancy Beach
                           Director of Disability Services
                           Ferrum College
                           PO Box 1000
                           Ferrum, VA 24088

                           nbeach@ferrum.edu
                           540-365-4262
                           540-365-4271 (fax)

                           AHEAD-VA Federal Tax ID: 54 -1552106

Section 4: Access Information:

Dietary restrictions (please specify): ________________________________________




Accommodations needed (check all that apply):

_____ Sign language interpreter                 _____ Assistive listening device

_____ Note-taking assistance                    _____ Alternate text (please specify):

                                                ______________________________

_____ Other: ________________________________________________________

								
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