Conference Registration (November 2Nd - 3Rd)

2011 National Lifespan Respite Conference Cultural Diversity Phoenix, Arizona - November 1st - 3rd, 2011 Issues! The May 22-24, 2006 Many Service Delivery Registration Form Options! Faces of Please print neatly & complete a separate form for each attendee. Respite First Name: Last Name: Organization: E-mail: Address: City: State: Zip Code: Phone #: Fax #:

Conference Registration (November 2nd - 3rd): (Includes all Conference Materials, Continental Breakfast, and Lunch each day) Vegetarian Plate Requested Early Registration - (Paid on or before September 16th, 2011) ARCH and Arizona Coalition Members (membership will be verified) $175 Non-Members $215 Standard Registration - (Paid on or after September 17th, 2011 – Registration Closes 10/21/11) ARCH and Arizona Coalition Members (membership will be verified) $200 Non-Members $240 Pre-Conference Intensive - Arizona Respite Summit (November 1st): (Includes all Summit Materials and Lunch, 10:00 AM – 4:00 PM) Early Registration - (Paid on or before September 16th, 2011) $50 Standard Registration - (Paid on or after September 17th, 2011 – Registration Closes 10/21/11) $60 Special Member’s Combo Registration including Pre-Conference (November 1st - 3rd) Early Registration - (Paid on or before September 16th, 2011) ARCH and Arizona Coalition Members Only (membership will be verified) $210 Standard Registration - (Paid on or after September 17th, 2011 – Registration Closes 10/21/11) ARCH and Arizona Coalition Members Only (membership will be verified) $235

Workshop Presenter Registration (special code needed) Presenter Code: $125

Total Registration Fees Due $ Special Needs/Accommodations: Persons with a disability may request a reasonable accommodation by contacting Dorothy Kelly at 602-285-0505, ext. 176, or email her at [email protected]. Requests must be made by October 7, 2011 in order to allow time to arrange for your requested accommodation. **For ADA accessible sleeping room, please specify at the time you make your hotel reservation. Method of Payment: (All fees are non-refundable.) Check payable to: FSL / Arizona Caregiver Coalition Purchase Order #: *Payment must be received prior to any applicable deadline. Credit Card (select one): Master Charge Visa Discover Card American Express

Name on Card: Card #: Security Code: Exp. Date: / Card Billing Address (if different than above): Enter total $ amount to be charged to your credit card: $ Authorized Signature:

2 Ways to Register: (We encourage you to register on-line for maximum security and prompt attention!) On-Line at www.azrespite.org/manyfaces and at www.archrespite.org. Mail completed form, including credit card info or check/purchase order payable to the Arizona Caregiver Coalition to this address: Arizona Caregiver Coalition, 1201 E. Thomas Road, Phoenix, Arizona 85014 **Registration for the AoA Grantee’s Meeting on 11/4/11 is a separate process on the ARCH website (www.archrespite.org)

SLEEPING ROOMS: A special room rate of $169 plus tax (single/double occupancy) has been negotiated with the Glendale Renaissance Hotel. Go to www.azrespite.org/manyfaces or more information. Reserve your room early - there are a limited number of rooms available at this special price. The deadline for the special rate is September 30 th. Discount code is “Lifespan Respite Conference”.