Veteran/Caregiver Registration Form
(for first-time Convention attendees)
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Name (as it will appear on badge)
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Caregiver Name (as it will appear on badge)
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Address
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City State Zip/Postal Code
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Daytime Phone E-mail
□ I plan to attend on the following day(s):
□ Thursday □ Friday □ Saturday
RSVP for special events
Get Acquainted Party (Thursday, June 22) RSVP: ____YES ____ NO
HLAA Stars Come Out – Awards Ceremony & Talent Show (Friday, June 23) RSVP: ____YES ____ NO
Mormon Tabernacle Choir Performance (Sunday, June 25) RSVP: ____ YES ____NO
ADDITIONAL Event Tickets
All Convention-related activities including the exhibit hall, workshops, and plenary sessions (Opening Session, Research Symposium, HLAA Stars Come Out), are complimentary except for the Saturday evening dinner theater:
□ Cranky Cochlea Dinner Theater (Saturday, June 24) $65 x _____$______
Special Dietary Requests
Primary Attendee: ____Vegetarian ____ Low Sodium ____ Diabetic ____ Gluten Free
Second Attendee: ____Vegetarian ____ Low Sodium ____ Diabetic ____ Gluten Free
pAYMENT INFORMATION
□ Check payable to Hearing Loss Association of America □ Visa □ MC □ AMEX □ Discover
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Card Number Expiration Date CSC Security Code
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Cardholder’s Name (as it appears on your card) Cardholder’s Signature
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Cardholder’s address (if different than above)
Return this form to:
Hearing Loss Association of America
ATTN: Niaz Siasi, Meeting Planner
7910 Woodmont Avenue, Suite 1200
Bethesda, MD 20814
Or, fax to 301.913.9413
Or, scan and email to
Or, bring it with you and we’ll be happy to process your registration on-site.
The Hearing Loss Association of America’s HLAA2017 Convention is a three-day event with an educational program, plenary sessions including a research symposium, Hearing Aids and Cochlear Implants: Merging Technologies, Expanding Benefits, Exhibit Hall, social events and more. Should you have any questions, please contact Niaz Siasi, Meeting Planner at or call 301.657.2248. See more information at www.hearingloss.org.