Group Registration for Agencies ONLY

Register Here!

Online Conference Registration Form
Group Registration ONLY

Please complete the following information to register for the Alaska Family Child Care Association's 21st Annual Child Care Conference, "Leaving Handprints On The World" on April 30 and May 1, 2010 at the Millennium Alaskan Hotel, Anchorage, Alaska.
Agency Name:
Contact Name:
Street Address:
Mailing Address:
City:
State:
Zip/Postal Code:  (5 digits)
Business
Phone:		  
Facility Email:
Verify Email:
PLEASE NOTE: All attendees on this form will be charged to the same credit card. 
Please use a separate form for each attendee using a difference credit card.
Attendee #1:


Name:
Email Address:

Conference Registration:

Special Meal Arrangements:



 Please indicate how you wish your name to appear on the conference attendee name tag. 



Please indicate if you need special Meal Arrangements?

Note any Food Allergies or Meal Restrictions:
Attendee #2:


Name:
Email Address:

Conference Registration:

Special Meal Arrangements:




 Please indicate how you wish your name to appear on the conference attendee name tag. 



Please indicate if you need special Meal Arrangements?

Note any Food Allergies or Meal Restrictions:
Attendee #3:


Name:
Email Address:

Conference Registration:

Special Meal Arrangements:



 Please indicate how you wish your name to appear on the conference attendee name tag. 



Please indicate if you need special Meal Arrangements?

Note any Food Allergies or Meal Restrictions:
Attendee #4:


Name:
Email Address:


Conference Registration:

Special Meal Arrangements:


 Please indicate how you wish your name to appear on the conference attendee name tag. 



Please indicate if you need special Meal Arrangements?

Note any Food Allergies or Meal Restrictions:
Attendee #5:


Name:
Email Address:


Conference Registration:

Special Meal Arrangements:


 Please indicate how you wish your name to appear on the conference attendee name tag. 



Please indicate if you need special Meal Arrangements?

Note any Food Allergies or Meal Restrictions:
More Attendees?  If Yes please complete an additional registration form.
Details:

Early Bird:
Must submit before March 15, 2010.
 Full Conference: 
        Member $150.00 Early Bird or $170.00
        Non-Member $170 Early Bird or $190.00
Friday or Saturday Only:
        Member $85.00 Early Bird or $95.00
        Non-Member $95.00 Early Bird or $105.00
Please Note:
There is an additional $25.00 for all on-site registration.
AFCCA Member? Is your group a member of the Alaska Family Child Care Association? 
Please List Members Here:
Please Note:     We will verify your current membership status.  If your membership has expired, please choose the following options:
Bill me $30.00 for Individual Membership in addition to my conference registration at the member rate.
Charge me the non-member conference rate.
Notify me, please do not process my registration.
Do you wish to become a member of the Alaska Family Child Care Association?
Yes, Bill me $30.00 for Individual Membership in addition to my conference registration at the member rate.
No, Bill me at the non-member conference rate.
Billing Information:
Name on
Credit Card:
Credit Card Number: Please indicate your credit card number without dashes or spaces.
Card Expiration:     
Security Code:

 Please indicate the three digit security code on the back of the card.
Billing Address: Billing Address same as above.  If not, please indicate it below.
Billing Address:




dsk 1-1-2010

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