Registrant Name
Registrant Title
Bd/Agency
Bd/Agency Address
City, State & Zip
Country
Phone
Fax
Email
In Case of Emergency During Conference	Please Contact  Daytime Phone Evening Phone
Cost	$275 - REGISTRATION FEE (per person) The full conference registration fee provides you with a program packet, workshops, two breakfasts, two lunches, opening reception and all breaks
Personal Assistant	I am a Personal Assistant who will be assisting (separate registration required)   (name required) during the conference.  A Personal Assistant is someone who assists people with disabilities with tasks essential for daily living. These tasks include bathing, dressing, getting around, toileting, eating, etc.  There is a special conference rate for Personal Assistants of $125.
Meal Choices	Please check all meals you plan to attend (Meals are included in the cost of the conference registration): Tuesday Reception Wednesday Breakfast Wednesday Lunch Thursday Breakfast Thursday Lunch
Disability Accommodations	Disability accommodations (including dietary and alternative format) will be provided when written requests are received 10 business days prior to the conference.  Clearly state your specific needs below.  On-site requests will be attempted, but cannot be guaranteed.
Payment Type	Payment DOES need to accompany registration form.  Please note that confirmation letters will NOT be sent.  If you require confirmation, please contact Annette Pepper at apepper@macmhb.org Mail check payable to:  MACMHB, 426 S. Walnut,  Lansing, MI  48933 PO # Credit Card
Credit Card Type	Visa   Master Card   American Express   Discover
Credit Card Number
Expiration
Contact Person	(in case of problem with payment)
Phone Number
Cancellation Policy	Substitutions are permitted at any time. No shows will be billed at the full training rate. Cancellations must be received in writing at least 10 business days prior to the training.  All cancellations will be assessed a $25 administrative fee. If cancellation is received less than 10 business days prior to the training, no refund can be given.