Creating A Legacy of Success
Conference
Registration Form
DEADLINE: February 28, 2014
Section 1: Personal Information
First Name:
Last Name:
Institution:
Job Title:
Postal Address:
City: Milledgeville
State/Province: ______Zip/Postal Code:
Telephone:
TTY:
FAX:
Confirmations will be sent via email
E-mail will be used for timely updates regarding event.
Please enter your e-mail address here:_
Please check all that apply:
Type of Institution:
Four year college or university
Two year college
Private Institution
Public Institution
Techincal College
Member of University System of Georgia Institution (USG)
Member of Technical College System of Georgia (TCSG)
Experience as DSP in Higher Education:
New Professional (0-3)
Mid-Level Professional (4-6)
Senior Level Professional (7-10+)
I am a:
Past member of Georgia AHEAD
New to Georgia AHEAD
Section 2: Access Information
Please check if applicable:
I will need a Vegetarian Meal
Other (i.e., allergies, etc.):
Programmatic Accommodations
I will need:
Sign Language Interpreter
Language preference:
Orientation and Mobility Assistance
Other:
I will need alternate media in the following format (select one):
Large Print Agenda and Handouts
Electronic Format emailed in advance
Other:
Section 3: Registration & Membership
If you are not a current GA-AHEAD member, you may renew your membership in addition to registration.
(Membership will be accepted for the new year July 1, 2014 to June 30, 2015)
- Registration received on or before February 28th, 2014
$55.00(current GA-AHEAD Member
$75.00(non-member)
- Membership options (skip section b, if you do not wish to join GA-AHEAD)
$25.00 (Annual individual membership from July 1st – June 30th)
$75.00(annual Institutional membership- 4 members from July 1st – June 30th)
Please list names of members for Institutional Membership.
______
Section 3: Subtotal $
Payment Information:Please enter totals from each section of the registration from here to obtain your grand total due.
Section 3a: Registration$
Section 3b: Membership$
Total Amount Due:$
Method of Payment:
Please check applicable form of payment. ALL REGISTRATIONS MUST BE SUBMITTED WITH AN APPROVED FORM OF PAYMENT. Registration via FAX requires payment by copy of your institutional purchase order.
Check Enclosed (Payable to: Georgia AHEAD)
Cashiers Check Enclosed(Payable to: Georgia AHEAD)
Purchase Order Enclosed
FEIN #58-1990946
CANCELLATION POLICY: All cancellations must be received in writing. No refunds.
NOTE: Registration fees are fully transferable to another individual from the same institution by making such request in writing to be received by no later than February 28, 2014
All checks made payable to: Georgia AHEAD
REGISTRATION DEADLINE: February 28th, 2014
Please save and submit this form to:
Fax
Subject box: Georgia AHEAD Fall Conference