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Georgia Peach Cochlear Implant Association Family Retreat - 2010 Registration Form Cohutta Springs Conference Center Crandall, Georgia July 9-11, 2010 Name Spouse Address City State Zip E-Mail Address Home Phone ( ) Work Phone ( ) Number Attending: Adults Children Ages (Complete attached form for Childcare) REGISTRATION FEES: $50.00 - ADULT (EACH) – Registration & Meals $20.00 - CHILD (EACH) – Registration & Meals LODGING: Please note that room availability is only guaranteed if reservations are made prior to June 1, 2010. After, June 1, 2010 you will have to make your own reservations with Cohutta and room prices will be higher. Room rates include 5% Room tax. No pets allowed on the property. NIGHTS REQUESTED: ____ Friday ____ Saturday ____ Friday & Saturday ROOM PREFERENCE: (subject to availability) ___ Standard Room - 2 Queen Beds $96.00/night ___ Handicap Access Room - 1 Queen Bed $96.00/night Will you be attending? (Please check) ___ Friday Night Hospitality ___ Saturday Breakfast ___ Saturday Lunch ___ Saturday Night Dinner ___ Sunday Breakfast ___ Sunday Lunch (not included in registration fee) Total Lodging $ Registration Fees: $ Late Registration Fees (After 6/15/10) $ 25.00 Adult $ Children 1 to 12 years $ **NOTE: Total Registration $ DONATIONS TO *GPCIA Membership Dues $ 15.00 GPCIA ARE 100% **GPCIA Donation $ TAX DEDUCTIBLE TOTAL COST $ _______ Check payable to GPCIA _______ Please charge to my credit card Circle: VISA MasterCard Discover Card number___________________________ Expiration Date ________________ Name as it appears on credit card_______________________________ Signature:__________________________________________________ NOTE: Please have credit card with you. Method of payment cannot be changed at retreat st * Membership is $15.00 annually per family, due June 1 . of each year. Membership includes newsletter and discount at Annual Retreat. Please add Membership dues, if you wish to receive retreat discount. **Please mail membership dues and retreat registration payable to GPCIA to: GPCIA, Marcy Nader, 105 Garden Court NE, Sandy Springs, GA 30328 For more information, Contact: Carol Underhill - Phone (678) 428.6354, or email at: email@example.com Connie Stratigos - Phone (770) 992-9707, or email at: firstname.lastname@example.org Marcy Nader – Phone (770) 351-9125, or email at: email@example.com NOTE: Register before 4/1/2010 to be placed in drawing for FREE Weekend Room! Envelope must be postmarked by April 1st to be eligible for the drawing. Recreational Activities Most recreational activities will be available on Friday and Sunday for a fee. On Saturday, the following activities will be available for your usage – canoes, paddleboats, pontoon boats, petting zoo, low ropes course. The swimming pool will be available for a certain time frame each day. On-Site and Single Day Registrations: Single day registrations (conference and meals, no lodging) for Saturday or Sunday are available at a cost of $35.00 per person, adult or child, plus GPCIA membership fee (one per family) unless membership dues have been paid in the previous 6 months. Assistive Listening Devices: Captioning will be available in the general sessions. Will you need an assistive listening device at the retreat? ___Yes ___No If so, what do you need? ___neck loop ___patch cord ___headset Membership Information: New Membership? ___Yes ___No Hearing Status: Implant User? ___ Yes ___ No If yes, type of device ____________________________ Date Implanted: ________________________________ Implant Candidate? ___Yes ___ No If yes, anticipated surgery date? _______________________________ Hearing Aid User ___ Yes ___ No I authorize GPCIA to share the above information along with my name, address, E-mail address, and telephone number with other GPCIA members/prospects or for education purposes approved by the GPCIA Board of Directors. Yes___ No___ Signed Date: REFUND POLICY: All requests for a refund of retreat registrations must be received in writing (letter or e-mail) by June 1, 2010. After June 1, 2010 refunds will only be granted in extremely extenuating circumstances and are made at the GPCIA Board’s discretion.
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