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"Building on our Strengths"

 

Registration Form

 

$200.00 includes meals and double occupancy lodging in newly renovated apartments (air-conditioned).

Single occupancy accommodations are available for $15.00 extra each evening.

Registration for this conference is non refundable. Please contact us if you have any questions.
Conference dress is casual.
Fields marked with an asterisk (*) will appear on your name tag

 

Please fill out the form below to register for the conference.

Registration deadline: May 1, 2008

 

Personal Information

* Title:
* First Name:	* MI:
* Last Name:
Address:
City:
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Zip Code:
Phone Number:
Fax Number:
Email Address :
* Position Title:
* Institutional Affiliation:
Special Dietary Considerations:	- Select - Allergies Faith-based Dietary Preferences Gluten free Vegan Vegetarian Other Other:
Requests for assistance:	- Select - Braille Language Translator Sign Language Interpreter Wheelchair Accessible
Any other considerations:
Transportation
Probable mode of transportation:
Flight Information for Harrisburg International Airport (MDT)
Arriving to the Conference:
Place of Departure:
Flight Number:
Arrival Time at MDT:
Departing the Conference:
Departure Time from MDT:
Flight Number:
Place of arrival:
Train Information
Arrival Time:
Departure Time:
Departure Location:
Destination Location:
Emergency Contact Information This information will be kept private and only will be used in the event of an emergency.
Name:
Relationship:
Phone number:
Your cell phone number:

Check here if you are interested in single occupancy rooms for an additional $15.00 a night.