9th INTERNATIONAL CHARGE SYNDROME CONFERENCE 


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Primary Contact:

First Name  Last Name  Relationship
                                           (Relationship to child w/CHARGE: Parent,Grandparent,Other Relative,Friend,Ind w/CHARGE,Caregiver)
Address   
City          State   Zip  
Province    Country  
Email       (Email Address is Required for registration confirmation) 
Permission to Share Information
Phone               Business Phone  
Organization  Professional---
Do you need sign language interpretation?     Yes  No       
Do you need Spanish language translation?     Yes No
Are you a presenter at this conference?       Yes  No
Are you a member of the CHARGE Listserv?      Yes  No
Please sign me up to receive the CHARGE Accounts newsletter via e-mail
Yes, I have read and agree to abide by the CHARGE Conference Policies    Review Policy
            (Required for Conference Attendance)
___________________________________________________________________________________________________

Additional Adults:
     (Please list Spouse first, if attending)

First Name Last Name    Spouse Yes  No
      City  State           Country  
      Sign language interpretation needed? Yes No  Relationship   
      Spanish language translation needed? Yes  No
      Member of the CHARGE Listserv?       Yes  No
First Name Last Name
      City  State           Country  
      Sign language interpretation needed? Yes  No  Relationship  
      Spanish language translation needed? Yes  No
      Member of the CHARGE Listserv?       Yes  No
First Name Last Name
      City  State           Country  
      Sign language interpretation needed? Yes  No  Relationship  
      Spanish language translation needed? Yes  No
      Member of the CHARGE Listserv?       Yes  No   
_______________________________________________________________________________

Children/Youth (under 16):            Click here to read about Childcare and Sibshop     

First Name Last Name Date of Birth
 (mm/dd/yyyy)		 Gender CHARGE Childcare Sibshop

M F

 YesNo
M F YesNo
M F YesNo
M F YesNo

 

   

 

 

 

 

If applicable, please remember to fill out the separate childcare registration form
___________________________________________________________________________________________________       

Attendance:
Will you be staying at the Hilton Chicago/Indian Lakes Resort?   Yes  No

Arrival:    Date    Time
Departure:  Date    Time 
___________________________________________________________________________________________________

Registration Fees:
Current Member Yes No  (If no, you may include membership with this registration)     Amount: 
Membership Registration included:                  
                                      Enter # Attending     
Children under 16, not attending childcare    X $ 95            
Children attending childcare                  X $175             
Members, including family members 16 & up     X $175            
Adult non-members                             X $215            
One-Day Option                                X $115            
Professional Day (July 23)  (no childcare)    X $ 90            
Late Fee:  after June 15                        $ 50                   
Yes, we want to help The Foundation with our donation of:            
                                                           TOTAL FEE:  
__________________________________________________________________________________________________


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_______________________________________________________________________________

 

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You may pay your registration fee on-line after form submission or at any time in the future via our website using PayPal.   Make any checks payable to CHARGE Syndrome Foundation, Inc.  Mail checks or money orders to the address below.  If you wish to pay by credit card, you may call us at the phone number listed below or send us your credit card information including name on card, billing address, card type, expiration date and the 3-digit CVV on the back of the card.

You will receive e-mail confirmation of your registration within 10 days.
If you fail to receive confirmation, please call us at the number below or
contact us at info@chargesyndrome.org.

If you have any questions or concerns about this form, please call us at the number below.

If you have children attending childcare, you must fill out the separate childcare registration.

Payments received after June 15 will be subject to a late fee of $50.
ABSOLUTELY NO REGISTRATIONS WILL BE ACCEPTED AFTER JUNE 30.

Mailing Address:
CHARGE Syndrome Foundation, Inc.
141 Middle Neck Road
Sands Point, NY 11050
800 - 442-7604

To-Do Checklist for Conference Attendees:

·         Make hotel reservation

·         Fill out the separate childcare registration, if applicable

·         Contact The Foundation if you don’t receive e-mail confirmation within 10 days

·         Pay prior to June 15 to avoid a late fee