Georgia Peach Cochlear Implant A by liwenting


									                                        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                          $
                        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_______________________________
NOTE: Please have credit card with you. Method of payment cannot be changed at retreat

* 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:
                               Connie Stratigos - Phone (770) 992-9707, or email at:
                               Marcy Nader – Phone (770) 351-9125, or email at:

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:


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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