Mail Completed Registration Form To: National Organization for Human Services

2014 Annual Conference in Marion, IN

March 13-15, 2014

Registration Form

Mail Completed Registration Form to: National Organization for Human Services

1600 Sarno Road Suite 16

Melbourne, FL 32935

Name:Title:
Address:
City:State:Zip:
Telephone:Email address:
College/University or Organization/Agency:
Conference Registration Information (Please make check payable to NOHS)
Registration fee covers Thursday evening reception, Friday breakfast & lunch, Saturday breakfast & lunch, and conference materials.
Please check category / Before Feb. 14th / After Feb. 14th / On-Site / Friday Only
Educator/Practitioner
(includes one-year NOHS/MWOHS membership) / $225 / $245 / $260 / $195
Student (includes NOHS/MWOHS membership) / $110 / $120 / $120 / $85
Educator/Practitioner – current NOHS member / $140 / $160.00 / $175.00 / $110
Student – current NOHS member / $85 / $95.00 / $105.00 / $70

GROUP RATES!

Student groups of 5 or more: $10 off each registration - registrations must be received by February 14, 2014 to be eligible.

Faculty/practitioner: 3 or more from same facility: $15 off each registration - registrations must be received by February 14, 2014 to be eligible.

Please indicate which group you are affiliated with:

Guest Meals: Meals are included in your registration. If a guest is joining you (spouse, partner, child, etc.) please indicate which meals your guest will be joining us:

Fri Breakfast ($8)Fri Lunch ($16)Sat Breakfast ($8)Sat Lunch ($16)Total: ______

Special Meal Requests:VegetarianLow Sugar/Controlled CarbohydrateOther : ______

Cancellation Policy: All cancellation requests must be received in writing and postmarked or emailed to MWOHS by or beforeFebruary 21, 2014.

No refunds will be given after this date. There is a processing fee of $50 for all conference cancellations.

/ National Organization for Human Services

Membership Application Form

Type: New Member

Category:  Regular $95  Student $35  Retired $60
Discount applies to conference attendees.

Please note Membership Fees are non-refundable.

MWOHS region

Member Information:

First Name:______MI:______Last Name:______

Position:______Institution:______

Primary Address (for membership mailings, newsletters, etc.):

Address: ______

City: ______State:______ZIP:______

Secondary Address:

Address: ______

City: ______State:______ZIP:______

Note when to use Secondary Address (example: Use June-August):______

Work Telephone:______Home Telephone:______

Fax:______Email:______

Students: Expected Grad Date:______College:______

What is your preferred method of communication? Mail Email Fax

May NOHS send you email?  Yes  No May NOHS send you faxes?  Yes  No

Payment:  Check enclosed  VISA  MasterCard

Card #:______Exp______Cardholder ZIP Code:______

Name on Card:______Signature:______

Mail to:National Organization for Human Services

1600 Sarno Road Suite 16

Melbourne, FL 32935