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Registration |
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Registration |
Name:
Mailing Address:
E-mail address:
Phone: (daytime preferred)
please
include area code.
Fax: (if available)
Name of Organization/Clinic/School:
Access:
I need wheelchair access
I need an
ASL interpret
I have other special needs (specify):
Roommate Service:
Some registrants will have extra space in their hotel room. We are willing to try to match these people up with registrants who need hotel space. Please let us know if you want to participate in this service.
I will need a roommate for my hotel room. (please note your hotel here if known: )
I need to be matched with someone who has space in her/his room
Child Care:
We expect to be able to provide child care for a limited number of children for $15/day. Children must be between the ages of 2-8 years old. We regret we cannot accommodate infants or older children and confirmed advance reservations for child care are required.
I need child care. My child isyears old.
Child's name:
Community Housing:
We expect to have a limited number of spaces in homes of Chicago area
residents for conference registrants who do not wish to stay in a hotel.
We regret that we will not be able to fulfill last minute requests for community
housing.
I need community
housing (we cannot guarantee free housing space but we will attempt to meet
all requests)
for Friday, September 11 Saturday, September 12
I will be driving
to the conference I
have allergies to cats and/or dogs
Non-smoking space
Fees:
$75 Regular fee
(Registration forms mailed after August 28 may not be
received before the conference. Please register by FAX
(773-561-1830), or at the door.).
Note: You can submit this form electronically and fax or mail
us your credit card number.)
$100 after September 8
$30 (special discounted student rate)
Enclosed is my check/money order for $ payable to "LCCP"
Please charge $ to Credit Card #: _____________________________
Note: For your safety, you will need to mail or fax your credit
card number to us. We cannot guarantee the security of your number if you
send it us by e-mail and you risk the potential of unauthorized use should
someone intercept it.
MasterCard
Visa
Name as it appears on your card: Expiration date: / (in month/year format)
I am attending the conference and I would like to make an additional donation of $to support the conference's efforts to keep registration fees low.
I am not able to attend the conference but I would like to make a donation of $to support the organizer's efforts to keep registration fees low and to assist in the important work of the conference.
This web site does not have a secure server. You may either print and mail this form to LCCP, fax it (if you are paying by credit card), or submit this form using the "register me" button below. If you submit this information via theweb, mail or fax us your credit card number rather than send it over the Internet.
| Mail registration forms and checks/money orders/credit card # to: | Fax registration forms with credit card information to: |
| LCCP Conference Planning Committee 4753 N Broadway STE 602 Chicago, IL 60640 |
773-561-1830 |
Due to competing conferences, very few hotel beds are available for our weekend in Chicago. Make your reservations early to guarantee your space. We will update the web site as we are able to secure hotel space.
When you have completed everything above:
If you need to start over again,
Please note, your information has to be converted into an e-mail message. This may take several seconds (5 to 30 seconds) so please be patient. Depending on how your browser is configured, you may also be warned that you information is not "secure." That is why we do not ask for credit card numbers on this form. Please wait for the next page which will tell you that your registration form has been delivered. Thanks!
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