Name __________________________________________________________________________________________
Title_____________________________________________________
Organization__________________________________________________________________________________________
Address______________________________________________________________________________________________
City_________________________________________________State_____________________Zip____________________Day
Phone_________________________________________e-mail_____________________________________________
List any special accommodations (please be specific)______________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
AE #_____________________________________________ Expiration Date _________
Registration is $150.00 prior to September 15th. Registration after September 15th and onsite is $175.00
Meals included in registration fee are: Breakfast on Monday-Wednesday for guests at the hotel, Dinner Monday evening, Lunch on Tuesday.
Refund Policy: Refund requests must be in writing, and $50.00 processing fee will be deducted from each refund.
Registration fees or Purchase Order numbers must be received at time of registration.
Registration before September 15th $150 ______
Registration after September 15th $175 ______
Total $______
Mail your completed form and fee to:
Michelle Stone, Coordinator
2000 Conference on Aging & Developmental Disabilities
1548 Deer Lake Dr.
Lexington, Kentucky 40515
If you have any questions please feel free to contact Michelle Stone
Phone at 859-273-9656 by Fax 859-272-6001 or E-mail momlex@aol.com>