Hearing Loss Association

What does your Leader/Delegate registration include? State and Chapter Leader meetings on Wednesday, June 21 Exhibit Hall Grand Opening and Opening Session, Thursday, June 22 Get Acquainted Party (GAP), Thursday, June 22 Leaders and Research Symposium: Hearing Aids and Cochlear Delegates must have a current Implants: Merging Technologies, Expanding Benefits HLAA membership. on Friday, June 23 Unlimited entry to Exhibit Hall and Socials

All workshops, demo presentations and featured speakers HLAA Stars Come Out, Awards Ceremony and Talent Complimentary Show, Friday, June 23 (please RSVP below) Cranky Cochlea DinnerState/Chapter Theater (A Gael Leader Hannan and Delegate Registration After 3.31.17, Extra Cost Applies Production) Circle your registration package below. use the regular attendee By 3.31.17 By 5/31/17 registration form Mormon Tabernacle Choir Performance – Sunday, June Complimentary (regular registration State25 Leader (up to four state officers and one delegate $125(please RSVPSee below) Attendee rates apply). per state may register using this form) Registration form Chapter Leader (up to four chapter officers and one $125 delegate per chapter may register using this form) Chapter Coordinator $125

Registration Package Total $______

□ Cranky Cochlea Dinner Theater (Saturday, June 24) 65 x _____$______

RSVP FOR SPECIAL EVENTS Get Acquainted Party at CaptionCall (Thursday, June 22) RSVP: ____YES ____ NO HLAA Stars Come Out – Awards Ceremony & Talent Show (Friday, June 23) RSVP: ____YES ____ NO Mormon Tabernacle Choir Performance (Sunday, June 25)- NEW EVENT RSVP: ____ YES ____ NO

ADDITIONAL EVENT TICKETS Use the section below to purchase tickets for your guest who is not otherwise registering. □ HLAA Stars Come Out Awards Ceremony & Talent Show (Friday evening, June 23) $25 x _____$______□ Cranky Cochlea Dinner Theater (Saturday, June 24) $65 x _____$______

Special Dietary Requests Primary Attendee: ____Vegetarian ____ Low Sodium ____ Diabetic ____ Gluten Free Second Attendee: ____Vegetarian ____ Low Sodium ____ Diabetic ____ Gluten Free

Tickets Total $______

Is it time to renew your HLAA membership? Membership □ New □ Renewal □ Individual $35/1yr □ Individual $95/3yr □ Individual $140/5yr □ Couple/Family $45 □ Professional $60 □ Student* $20 *For student membership please enclose copy of student I.D. card.

Registration Package Total (from front) CONTRIBUTION $______Contributions help support the information, education, , support, and advocacy efforts of HLAA throughout the year. Donors who contribute to the Convention will be Tickets Total (from front) listed in the HLAA2017 Program & Exhibit Guide if $______received by April 30, 2017. Membership Total $______

Contribution Total $______Are you a young adult (age 18 – 30)? ____ Yes ____ No Do you use a smartphone? ____ Yes ____ No PAYMENT TOTAL $______

______Registrant (name as it will appear on badge) ______Address City State Zip/Postal Code ______Daytime Phone Email

______Full Name of State Organization or Chapter Role with State and/or Chapter

PAYMENT INFORMATION □ Check payable to Hearing Loss Association of America □ Visa □ MC □ AMEX □ Discover

______Card Number Expiration Date CSC Security Code

______Cardholder’s Name (as it appears on your card) Cardholder’s Signature

______Cardholder’s address (if different than above) Cancellation Policy Send form and payment to: The following policy applies to refunds of registration fees: Hearing Loss Association of America Cancellation on/or before March 31, 2017: Refund = full amount of registration fees and 7910 Woodmont Avenue, Suite 1200 event tickets less a $50 cancellation fee. Bethesda, MD 20814 Cancellation between March 31 and April 30, 2017: Refund = 75% of registration fees and [email protected] event tickets. phone 301.657.2248 fax 301.913.9413 Cancellation between April 30 and May 31, 2017: Refund = 50% of registration fees and event tickets.

No refunds will be made after May 31, 2017. Cancellation must be received in writing. Cancellation date will be determined by USPS postmark or email receipt date.

Please see hearingloss.org/content/convention for news and updates as well as the Code of Conduct policy.