Elder Rights and TRIAD Conference Elder Rights ... - State of Illinois

Confence Registration2010 Elder Rights and TRIAD ConferenceLast Name First Name Middle InitialTitleAgency/CompanyStreet Address City State ZipWork PhoneEmail AddressRegistration Fees:Day Registration Options Rates SeniorVolunteer/TRIADVolunteer/StudentRate7/14 ® I will be attending this day $75.00 $50.007/15 ® I will be attending this day $75.00 $50.007/16 ® I will be attending this day $75.00 $50.00Full ® I will be attending all 3 days $150.00 $100.00Lunch is included on all 3 days.Please indicate which or all lunches you will attend, as well as the reception, below.Wednesday Lunch Thursday Lunch Thursday Reception Friday Lunch® Yes ® No ® Yes ® No ® Yes ® No ® Yes ® NoPrinted by the Authority of the State of Illinois. 200 5/10 IOCI 0650-10Payment Options:Check or Money Order:Payable to 2010 Elder Rights/TRIAD ConferenceMail fee and registration to:2010 Elder Rights/TRIAD ConferenceIllinois Public Health Association223 S. 3rd Street, Springfield, IL 62701On-Line Registration:On-line registration is available when payingwith Visa or MasterCard at www.ipha.comYou may also contact IPHA by:E-mail: ipha@ipha.comFax: 217-522-5689;Phone: 217-522-5687TOTAL ENCLOSED: $___________The FEIN number for the conference is:36-6108-790.Cancellation Policy: Registrants who cancelprior to July 1, 2010, will receive a refund less a$25.00 administrative fee. Those cancelling afterthat date may transfer the registration to anotherperson in the same agency or organization. Allcancellations must be received in writing. If youhave any questions, please contact IPHA at217-522-5687 or by email to ipha@ipha.com.No refunds will be made after July 1, 2010.