Registration Form for
2002 "Edge of Discovery"
Kennedy's Disease Association Conference and Symposium
October 20-22, 2004
Please print this form out, fill it out completely and mail with your conference registration fees to:
Kennedy's Disease Association P.O. Box 1105 Coarsegold, CA 93614-1105 ----------------------------------------------------------------------------------------------------------------------------- This registration form does NOT register you for your hotel accommodations at the Holiday Inn Select in San Diego. You must make these arrangements yourself. Here is the information: Cost per night: $109.00 + tax - Rooms at this special conference price only until September 19, 2004 - You must mention that you are attending the KDA Meeting to get this discounted rate - Make your hotel reservations now!!! Space is limited. Hotel Reservation Lines: Toll-Free: 800-Holiday (800-465-4329) or Direct: 619-291-5720 ---------------------------------------------------------------------------------------------------------------------------- Names of Attendees as you would like E-mail Type of Attendee: KD Individual or them written on name badges: Addresses: Carrier? Family Member? Other? _________________________________ ________________ _____________________________ _________________________________ ________________ _____________________________ _________________________________ ________________ _____________________________ _________________________________ ________________ _____________________________ Where should we send your meeting confirmation and information packet: Mailing Address:___________________________________________________________City:____________________________________________ State:____________________
Zip Code:_____________________________ Phone Number: (______)_______________
We (do________) (do not_________) plan to go to the dinner mixer Wednesday night at (Restaurant to be named). We understand the cost of this dinner is NOT included in our registration fees. How many in your party are going to the Wednesday dinner mixer : ___________Number of Attendees: ______ x $160.00 (if registration prior to September 1, 2004) = $________
______ x $195.00 (if registration on or after September 1, 2004) = $________
I would like to also include a donation at this time in the amount of: $________
Total Amount Enclosed: $___________ Please note, there are no refunds of registration fees.