ASCLS Georgia Spring Meeting

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/