REGISTRATION Two options 1. Print and fill out form and send with check payment Registration Form PDF 2. Fill out form below and choose payment option CAPTASA 2024 Conference Registration Form CAPTASA 2024 Conference Registration Form January 27-28, 2023 Embassy Suites - Lexington, KY Contact Name * First Last * Last Profession/Credentials Name for Nametag * Institution/Organization Mailing Address * City * State * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip * Phone Fax Email * Please list any special needs you may have (dietary, etc.): I will attend * In Person Online Payment Information • Cost of Banquet NOT included in registration fee. • No one day, group rate or scholarships NO REFUNDS AFTER JANUARY 14, 2023 $250 Early Registration Fee (early registration ends January 5th, 2023) $300 Registration Fee (after January 5th, 2023) I plan to attend the banquet Friday night (cost $35) * Yes No # of guests @ $35 per ticket - Do not include yourself in this count. * # of Handouts @ $35 per set * MUST PRE-ORDER BY JANUARY 17 - NOT AVAILABLE FOR PURCHASE AT CONFERENCE - Handouts will be available online @ www.captasa.org for no charge. FOR EXPRESS REGISTRATION AT THE CONFERENCE: Print your receipt and bring it with you when you register in Lexington. Total If you are human, leave this field blank. Pay Now
