Fill and Sign therapy Therapy Contract Agreement Form

phada’s 2011 annual convention & exhibition May 15-18 in New Orleans, Louisiana at the New Orleans Marriott Hotel Don’t miss this opportunity to learn, share ideas and network with your colleagues from across the country. Register for the 2011 Annual Convention and Exhibition by April 8 for a discounted registration fee. Register for the conference: Reservations at the hotel: Register online at www.phada.org, or fill out the form below and mail or fax it, along with the registration fee, to: Call (800) 266-9432 to make reservations at the New Orleans Marriott Hotel. Mention that you are attending the PHADA meeting. PHADA Annual Convention and Exhibition 511 Capitol Court NE Washington, DC 20002-4937 Fax: (202) 546-4166 New Orleans Marriott Hotel 555 Canal Street New Orleans, Louisiana 70130 For hotel reservations go to www.phada.org for link. Reservation cut-off date APRIL 11 (Please fill out a separate form for each registrant, including spouses) Name ______________________________________________ First Name for Name Badge __________________________ Housing Authority ______________________________________________________ Title ____________________________ Street Address __________________________________________________________________________________________ City/State/Zip ___________________________________________________ Phone_________________________________ E-mail address (required to receive confirmation)_______________________________________________________________ Is this your first PHADA meeting? yes no Do you plan to attend the Bollinger Scholarship luncheon (included in registration fee) on Tuesday, May 17? Do you plan to attend the closing dinner (included in registration fee) on Wednesday, May 18? yes yes no no Please check this box if you require special services or assistance because of a disability. Executive Director Education Program D BIR ! (EDEP) registration Y L L R (conference registration is included) EA PECIA S Option 1: Friday, May 13 Legal Issues—$950 PHADA conference registration only (for those not taking EDEP classes) Before April 8 After April 8 On-site Option 2: Saturday, May 14 Procurement and Contract Management—$950 Member: $440 Member: $465 Member: $490 Nonmember: $550 Nonmember: $575 Nonmember: $600 Option 3: Both classes—$1450 Spouse: $170 Spouse: $180 Spouse: $190 Payment method: Check or money order enclosed in the following amount: $ _______________ Please bill my: MasterCard VISA American Express Account # __________________________________ Print Name __________________________ Signature ____________________________________ Exp. Date ____________________ * Cancellations received in writing before Friday, April 29, 2011 will be refunded less a $100.00 administrative fee. Substitutions are welcome if notified in writing. There will be no refunds after April 29, 2011. No refunds are given for no-shows. BY SUBMITTING THIS REGISTRATION FORM YOU ARE AGREEING TO PHADA’s CANCELLATION POLICY. EDEP registrants please note: On-site registrations are not accepted for the EDEP program, and class size is limited to 40 participants. You will receive confirmation of your EDEP registration from Rutgers University. If you do not receive a Rutgers confirmation, please contact the PHADA office at (202) 546-5445. Refunds will only be issued to registrants who withdraw on or before April 25, 2011.