LeadingAge Washington's 64th LeadingAge Washington’s 64th Annual Meeting & Conference Be The Voice Annual Meeting & Conference JUNE (8) 9-11, 2015 • GOLF TOURNAMENT JUNE 8 SEMIAHMOO BLAINE WA June 8th June (8) 9-11,RESORT, 2015 * Golf Tournament Semiahmoo Resort, Blaine, WA 1(855)917-3767 * Group Name: LeadingAge * (Cutoff Lodging Question: Lodging? (855) 917-3767 • Group Name: LeadingAge (Cutoff: May 15) May 15th ) REGISTRATION FORM Please duplicate this form for each person attending Name:_____________________________________Title:_________________________________________ Organization: ____________________________________________________________________________ Address:________________________________________City/State:__________________ Zip:__________ Phone:_____________________________________Fax:_________________________________________ Email: (Email required for confirmation) _________________________________________________________ To assist with meal counts, please indicate the functions you plan to attend: Tues. June 9th Breakfast___ Lunch___ “WA” American Idol Night with entertainment____ (Comp’d with registration) th Breakfast___ Lunch___ th Breakfast___ Lunch___ Wed. June 10 Thur. June 11 To request Guest meal tickets, contact Cassi! I PLAN TO HAVE ALL MEALS___! Special Dietary Requests or Needs:_____________________________________ Registration Fees includes sessions, meals, fun night and DSHS credits. Please mark appropriate boxes. Full Registration Through May 29th ***10% disc After May 29th/Onsite ___Member (M) $565.00 $508.00 $665.00 ___Non-Member (NM) $665.00 $599.00 $765.00 ___Resident, Board Member $275.00 $247.00 $325.00 & Administrator Emeritus Partial Registration check appropriate date and circle fee that applies ___ Tuesday, June 9 th $285 M $256 M $325 M ___ Wednesday, June 10 $285 M $256 M $325 M ___ Thursday, June 11 $195 M $175 M $235 M th th Optional Events ___ Golf, Mon., June 8th $125.00 includes lunch, range balls, cart and Awards dinner at the Loomis Trail Golf Club ___ Wine Event, Mon. June 8th $55.00 begins at Semiahmoo through the Heart of the Northern Wine Country. Includes Limo ___ Half-Day Education, Tues., June 9th $99.00 includes lunch, 11:00 - 4:30 p.m. Half-Day specific for Activity/Wellness, Social Workers and Resident Services Directors. Total Amount Due: $________ *** With 1 full registration, receive the 10% DISCOUNT for each addl. registrant. Payment Method: (Print Clearly) Credit Card_____ Check attached_____ Please Invoice________ Name on CC_____________________________CC#____________________________CSC#_______ Exp. Date___________ Signature ______________________________________________________ Return to: LeadingAge Washington Mail: 1495 Wilmington Drive, Ste 340, DuPont, WA 98327 Fax: (253) 964-8876 ׀Email: [email protected] $50.00 Cancellation fee after May 30th — No Show - No Refund * Replacements Welcome Consent to Use of Photographic Images—Registration and attendance at, or participation in, LeadingAge WA meetings and other activities constitutes an agreement by the registrant for LeadingAge to use and distribution (both now & in the future) of the registrant or attendee's image or voice in photographs, videotapes, electronic reproductions, and audiotapes of such events and activities.
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