Read Microsoft Word - RegForm40thNAPEC_Revised.doc text version

40th National Adapted Physical Education Conference "Navigating the Ever-Changing Waters" Long Beach Westin ­ Long Beach, CA November 17-19, 2011

Name Address City Work State Home Zip

Last First

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Email

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Employer/College

CAHPERD/AAHPERD or other state HPERD Membership ID# & expiration date ­ required to register at member rate ___________________________

Early Registration Rates**

Early Registration postmark deadline date is 10/15/11.

Check Meal Functions you will attend:

Thursday Opening Session (Space is Limited!) Thursday Social (Space is Limited!) Friday Breakfast/ General Session Saturday Awards Luncheon/ General Session

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Please check appropriate boxes.

A. B. C. D. E. F. G.

Professional CAHPERD Member $170.00 Professional Non-CAHPERD Member* $235.00 Paraprofessional $90.00 Speaker (must have received letter) Retired CAHPERD Member Student CAHPERD Member Student Non-CAHPERD Member $80.00 $85.00 $85.00 $90.00

Must include letter from superintendent with registration.

Payment Option:

Make checks/purchase orders payable to CAHPERD or fill in credit card information below

Credit Card # Credit Card Expiration Date (MM/YY) Name on Credit Card

NOTE: If registering in categories above, Meals are included. Please be sure to check boxes in the column on the right to indicate which meals you will be attending. Meal tickets will not be guaranteed if boxes are not checked. NOTE: Meals and Social can be purchased by checking selections below. Space is limited for Thursday Opening Session and Social! Book early!

Signature (required only for credit card transactions)

H. I. J.

Syllabus on-line Complimentary Meals (Guests) $80.00 Guest/ Spouse Thursday Social $25.00

Mail Early Registration with Payment to:

CAHPERD 1501 El Camino Avenue - Suite 3 Sacramento, CA 95815-2748 or fax to 916-922-0133 Early Registration postmark deadline date is 10/15/11** After 10/15/11 registration is only available on-site.

Please be sure to check boxes in the column to the right to indicate which meals you will be attending. Meal tickets will not be guaranteed if boxes are not checked.

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Registration Total

$__________ Early Registration postmark deadline date is 10/15/11.

HOTEL INFORMATION: Long Beach Westin Hotel http://www.napeconference.org/NAPEC40.htm

Group rate available until October 23, 2011. Subject to Availability. Phone: (562) 436-3000

Special Need Accommodations

Check if reasonable special need accommodations are requested and describe _____________________.

(Must be requested by 10/15/11 to guarantee service.)

After 10/15/11 registration is only available on-site.

*CAHPERD member registration rates may be obtained for non-members if CAHPERD membership is paid at the time of conference registration. Membership applications are available at CAHPERD by telephone, (916) 922-3596 or online at www.cahperd.org. .

AAHPERD and other state's HPERD membership are honored with proof of membership.

**All forms for Early Registration must be submitted with payment (check or Visa/MasterCard) and postmarked or faxed by 10/15/11. Registrations by Visa/MasterCard or PO may be sent by fax to (916 922 0133) and must be received by 10/15/11. If you are unable to meet this postmarked deadline, registration is only available on-site. No exceptions. On-site registration rates will be $65 higher in all categories, EXCEPT Retired and Student. On-site registration does NOT guarantee meals or social.

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Microsoft Word - RegForm40thNAPEC_Revised.doc