2002 MACRT-ASERT Conference Registration

Fill out this form, print it, and mail it to the address below. If you prefer, you can just print the blank form, fill it out by hand, and then mail it. (Select "Print" from the File Menu in your browser).

Contact Information:
Name:
Home or Work Address:
City:
State:
Zip Code:
Day Phone:
Night Phone:
Fax:
Email:
 
Registration Type (select one):
   Early Bird Registration $80.00
   Registration after 9/16/02 $100.00
   One-Day Early Registration$55.00
   One-Day Registration after 9/16/02   $75.00
   Student Registration $80.00
 Total: 
 
Conference Materials in (select one):
  Braille       Large Print       Regular Print

  Check this box if you would like vegetarian meals.

Mail this form and your check* payable to MACRT to:

Susan Dalton - TransVision Program
109 S. Jefferson Street, Suite #2
Woodstock, IL 60098-3465
Phone 815-206-0069

*Sorry, no credit cards.