Registration Form

Mail this form with check or purchase order for items selected to: CONFERENCE REGISTRATION,

Mid-America Congress on Aging, PO Box 892, Blue Springs, MO 64013-0892.

(Questions to Margy Ryan at 402-477-7357)

You may include your MACA membership in the same check. If you are a non-member and wish to join MACA, please fill out the form on the back of this page and return it with the appropriate dues rate and the special discounted MACA conference rate.

(Please print out or photocopy this form and provide individual forms for each person registering.)

Name:____________________________________________________________________________________

Firm/Company/Agency/Workplace:_____________________________________________________________

Address: Circle (home) or (work) _____________________________________________________________

City/state/zip+4 _____________________________________________________________________________

Daytime Telephone: (_____) _______________________ Fax: (_____) __________________________

Soc. Sec. # (required for CEUs) _____________________ E-Mail:_______________________________

EARLY REGISTRATION DEADLINE APRIL 7 (Register now for special Early-Bird rates!)

Full Conference (Fri.- Sun.) Check category below:

(Includes all plenaries, workshops, MACA member $200 $__________

receptions, breaks, and breakfast Non-MACA registrant $250 $__________

& lunch on Sat. & Sun.) Student (no meals included) $30 $__________

(After April 7, add $30 per registrant for late handling) $__________

Single Day (Specify day/s) Fri______ Sat_______ Sun______ @$100 per day $__________

CEUs (Specify program and license # if any) _______________________ $40 person $__________

Pre-Conference Discount Price on MACA's new book, "Aging and Mental Health"

Book may be picked up at registration ______ copies @ $12.95 $__________

Conference Abstract Book ______ copies @ $10.00 $__________

TOTAL $__________