1.  Personal Information

 Name

 Address

 City                                                  State         Zip

 Phone

  Email


 2.  Are you affiliated with any organizations?

  Would your organization like to have a literature table at the Conference($25)?
  Yes              No

3.  How did you hear about us?

4.  If you will be staying at a hotel, please indicate which hotel:

And what nights you are staying there?
Friday Night     Saturday Night

5.  If you need housing, please indicate which nights you need it:
Friday Night     Saturday Night
 and whether or not you need special accommodations (i.e. pet free house, child safe house, etc)

6.  Do you need meals?
Saturday Breakfast
Saturday Lunch
Sunday Breakfast

7.  Are you bringing children that will need supervising during the workshops?
  Yes      No

 If so, how many children?

8.  Conference Costs: $10 due by March 7th. How much will you be sending?