October 19-21, 2015 Declaration of Independence” “A AR APSE Conference Registration, Holiday Inn Conference Center - Airport Little Rock, AR Reservations: Please type or print all information. Use a separate form for each person registering for the Conference. Name Organization Address City _______________________State __________ Zip Phone _______________________ Fax TTY Personal Care Assistant will be attending. Registration fee required for one PCA-see below. Name of your PCA REGISTRATION COST (One registration form per attendee.) 2015 Pre-registration - Postmarked by September 15, Pre-conference Day October 19, 2015 50.00 individuals with disabilities, their family members, or partner(s) 100.00 professionals or others Conference Days October 20-21 75.00 Individuals with disabilities, their family members, or partner(s) 30.00 Accompanying Caregiver (cost covers meals) 100.00 APSE Members (Membership must be current) – 175.00 Non-APSE Members On-site registration not included) 100.00 Individuals with disabilities, family members, or partner(s) 200.00 APSE Members (Membership must be current) – 200.00 Non-APSE Members Accommodations please list - Make checks payable to: AR APSE-- PO Box 961, Little Rock, AR 72203 Latisha McClendon at 501-296-1651 or by email @ Contact:
October 19-21, 2015 “A Declaration of Independence” AR APSE Conference Registration, Holiday Inn Conference Center - Airport Little Rock, AR Reservations: Please type or print all information. Use a separate form for each person registering for the Conference. Name Organization Address City _______________________State __________ Zip Phone _______________________ Fax TTY Personal Care Assistant will be attending. Registration fee required for one PCA-see below. Name of your PCA REGISTRATION COST (One registration form per attendee.) Pre-registration - Postmarked by September 15, 2015 Pre-conference Day October 19, 2015 50.00 individuals with disabilities, their family members, or partner(s) 100.00 professionals or others Conference Days October 20-21 75.00 Individuals with disabilities, their family members, or partner(s) 30.00 Accompanying Caregiver (cost covers meals) 100.00 APSE Members – (Membership must be current) 175.00 Non-APSE Members On-site registration not included) 100.00 Individuals with disabilities, family members, or partner(s) 200.00 APSE Members – (Membership must be current) 200.00 Non-APSE Members Accommodations please list - Make checks payable to: AR APSE-- PO Box 961, Little Rock, AR 72203 Contact: Latisha McClendon at 501-296-1651 or by email @
AR-APSE-October-conference-Registration-form.docx