Please indicate your Association affiliation below
(this information is required for tracking purposes)
AEYC-MO
MHSA |
First Name: |
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Last Name: |
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Title: |
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Organization: |
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Street Address: |
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City: |
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State: |
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Zip: |
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Phone: |
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Fax: |
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Email Address: |
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Special Needs: |
Vegetarian Meals
Additional Assistance/Accommodations
Other
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Is the address listed above your billing address?
Yes
No
(If no, please provide billing address below) |
Billing Organization:
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Billing Street Address:
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Billing City:
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Billing State:
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Billing Zip:
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Registration Fee: |
$175.00 Standard Registration
$
200.00 Late Registration (received after November 4, 2008)
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Thursday Luncheon: (each organization will have a separate luncheon on Thursday. Please indicate which luncheon you will attend on Thursday to provide an accurate meal count)
AEYC-MO
MHSA
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Payment Type:
PO #
Check #
Credit Card
(link to CC payment form will be provided after registration is submitted
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Session seating is limited and assigned on a first-come, first-served basis. Please note that each workshop session has been assigned a unique identification number. Indicate your 1st, 2nd and 3rd choice bwelow. Workshop sessions are subject to change.
Please note: if 2nd and 3rd choice selections are not made and 1st choice session is full, workshop sessions will be assigned at random on a space-available basis. Likewise, if no session choice is indicated, workshop sessions will be assigned at random on a space-available basis. |
Block I: 1st Choice |
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Block I: 2nd Choice |
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Block I: 3rd Choice |
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Block II: 1st Choice |
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Block II: 2nd Choice |
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Block II: 3rd Choice |
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Block III: 1st Choice |
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Block III: 2nd Choice |
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Block III: 3rd Choice |
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Block IV: 1st Choice |
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Block IV: 2nd Choice |
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Block IV: 3rd Choice |
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