REGISTRATION FORM
ASCLS Georgia Spring Meeting
Children’s Healthcare of Atlanta Office Park
1680 Tullie Cir NE, Atlanta, GA 30329
Saturday, April 15, 2017
Name (Please print): ______
Address: ______
City, State, Zip ______
Phone(Cell/Home): ______(Work) Phone: ______
ASCLS Member #: ______
Please check one of the following:
ASCLS FYP, PF1, PF2 Member Professional Non-Member
ASCLS Student Member Student Non-ASCLS Member
Employer: ______
Email Address: ______
Registration Fees (postmarked on or before April 7, 2017) CASH or CHECK, to register and pay online, please visit www.asclsga.org
Please select one option(all include breakfast, lunch, and access to all vendor exhibitions and continuing education sessions):
ASCLS Student Member - $25.00
Student Non-ASCLS Member - $35.00
ASCLS Professional Member - $100
Professional Non-ASCLS Member - $125
Guest Speaker - $0.00
Bronze: $500 (Exhibitor booth at the Vendor Exhibits throughout the meeting)
Silver: $750 (Exhibitor booth and sponsor breakfast/lunch/break)
Gold: $1,000 (Exhibitor booth and sponsor a guest speaker)
Platinum: $1,500 (Exhibitor booth and sponsor a student travel grant scholarship to the ASCLS National Annual Meeting in San Diego, CA)
Organizations that sponsor speakers, breaks, etc. will receive honorable mention in our conference program and will receive spotlight posts on our Facebook page and website.
Additional Options for attendees/non-exhibitors:
Sponsor a break - $100 Sponsor a breakfast/lunch - $200 Sponsor a guest speaker - $300
Session moderators will introduce speakers and collect evaluations after the session.
Would you be interested in moderating a session?
Yes, I can pick up a packet at the registration table
No, thank you
Please check the box to indicate that you have attended any previous ASCLS conference:
Please submit completed registration form and payment (Cash or Check, payable to ASCLS-GA) postmarked by
Friday, April 7, 2017 to:
Crystal Bradley 262 Lafayette Dr.
Augusta, GA 30909
Registration may also be completed online and paid with credit/debit card by using the following link:
http://asclsga.org/spring-meeting-2017-registration/