REGISTRATION Form-1
NE/AER Regional Conference, 2015
Sea Crest Beach Hotel
N. Falmouth, MA
November 4-6, 2015
AER MEMBER #______
Name:______
Address:______
Street City State Zip
Phone:(h)(w)(c)______Secondary:(h)(w)(c)______
Email:______
Position/Job Title:______
Organization: ______
Please indicate any needed accommodations:
Braille: Large Print: Interpreter: Other:
Special Dietary Requirements:______
How did you hear about this Conference?______
Please indicate: Continuing Education Hours ACVREP PDP’s
Social Work CEU's Connecticut Teacher CEU's CRCC
PLEASE RETURN REGISTRATION TO:
Perkins Training Center
175 North Beacon Street
Watertown, MA 02472
**Checks MUST be made out to NE/AER
Payment must be received and confirmed in order to secure your participation.
**Conference cancellation after Oct. 23, 2015 will not be eligible for a registration refund
Page 1 of 5
REGISTRATION Form-2
2015 NE/AER Fall Conference
Determine rates from the table below and
enter on this Form
*AER MEMBERS MUST INCLUDE MEMBER # TO GET MEMBER RATE
NOT AN AER MEMBER? JOIN TODAY! Go to:
Membership Category / Member / Non-Member
/ Student
(# required) / Total
Pre-Conference -1 / $60. / $70. / $35.
Pre-Conference -2 / $50. / $60. / $35
Pre-Conference -3 / $50. / $60. / $35
FULL Conference / $220. / $395. / $155.
Wednesday ONLY
Includes banquet / $190. / $225. / $145.
Thursday ONLY
Includes breakfast and lunch / $150. / $195. / $120.
Friday ONLY
includes breakfast / $110. / $120. / $95.
Additional Dinner
Guest / $65. / $65. / $65.
TOTAL DUE
LATE FEE (if after October 1st add $50.00)
Conference Cancellation Policy:
Conference cancellations made after Oct. 23, 2015 will not be eligible for a refund of your registration fee (serious emergency exception)
Page 2 of 5
REGISTRATION Form-3
Make an extra copy for your recordsand
Mailoriginal with registration and payment. (Check one per session)
Wednesday, November 4
8:45 – 11:45
Pre Conference 1 Pre Conference 2 Pre Conference 3
2:30 – 4:00
W1W2W3W4 W5W6
4:15 – 5:15
W7 W8W9 W10 W11 W12
Thursday, November5
10:30 – 11:30
T1 T2 T3 T4 T5 T6
1:00 – 2:30
T7T8T9 T10 T11 T12
3:00 - 4:00
T13T14T15T16T17 T18
4:15 – 5:45
T19T20T21 T22 T23
Friday, November 6
9:15 – 10:45
F1F2 F3F4 F5
11:00 – 12:00
F6F7 F8 F9F10 F11
Page 3 of 5
REGISTRATION Form-4
Menu Selection
Please select your banquet (dinner) choice
and/or your box lunch choice
Banquet-Wednesday Nov. 4
Seared East Coast salmon, lemon scented jasmine rice, french beans, baby carrots, charred tomato beurre blanc
Green apple honey brined free range chicken, grilled vegetable tian, pasta torta, grain mustard jus
Provencal vegetables, angel hair flan, and heirloom tomatoes
Other (Please Specify-Vegetarian, Gluten Free, other, etc.)______
Boxed Lunches-Thursday Nov.5
Honey roasted turkey breast, Vermont cheddar, vine ripe red and yellow tomato, Bermuda onion, leaf lettuce, herb ranch mayo on a fresh bulky roll
Smoked ham, baby Swiss, vine ripe red and yellow tomato, Bermuda onion, dill pickle, leaf lettuce, dijon, aioli on marble rye
Pesto grilled free range chicken, local goat cheese, fire roasted pepper mayo, vine ripe red and yellow tomato, leaf lettuce on a fresh bulky roll
Caesar salad wrap, hearts of romaine, creamy peppercorn dressing, country croutons, baby tomatoes, cured olives, shaved parmesan cheese
Other (Please Specify-Vegetarian, Gluten Free, other, etc.)______
Page 4 of 5
REGISTRATION Form-5
2015 NE/AER Fall Conference
Payment Options
1-Check- Make Check Payable toNE/AER Conference 2015
OR
2-Purchase Order- Enclose PO with completed individual registration(s) forms for All participants
AND complete the following:
Agency Name:______
Address:______Contact Person:______
Phone: ______email:______
AER MEMBER #______
*MAIL (5) Forms
To:
Perkins Training Center
175 North Beacon Street
Watertown, MA 02472
Attention: Teresa Pagliuca
* (INLUDE THIS PAGE FILLED OUT IF USING PO)
Conference cancellation after Oct. 23, 2015 will not be eligible for a registration refund
Page 5 of 5