2012 ITRA Registration

Fax:
319-273-7470 		Questions?
319-273-5141
Mark the appropriate box that most closely represents your area of service.
Community Rehabilitation Education Geriatrics
MR/DD Pediatrics Mental Health Long Term Care
I am a student. Other (please specify):
 
Contact Information

Name
First MI Last

School/Organization:

Work P.O. or Street Address:   

City:
County:
State:
Zip:
Day Phone:
(including area code)
Fax:
(including area code)
Fax:

Email:
Please list any special needs, including dietary:
Check here if you'd prefer a vegetarian meal.
 

Registration Information

Please register me
received by 3/26
received after 3/26
ITRA Member
$90
$105
Non ITRA Member
$100
$120
Board Member
$25
Student
$25
Speaker
$0
Make payment for conference registration to UNI-UEC.
I would like to receive .9 CEUs for both days.
$10
I would like to receive .7 CEUs for Friday only
$10
I would like to receive .2 CEUs for Thursday only
$10
Please do not include my name in the membership directory.
Do not share information about my participation with my local news media.
     

Session Selection
(choose a number for each time)

9:10 am 1 2 3 4 5  
10:20 am 1 2 3 4 5    
1:45 pm 1 2 3 4 5    
2:55 pm 1 2 3 4      
4:00 pm 1 2 3 4      
Click here to see the brochure which lists the topics for each session.
 
Payment Information

Submitting payment: Please check your preferred method of payment below. We will send you an invoice with your confirmation letter.

Check or credit card
Note: For security purposes, we will request specific credit card information on your invoice.

Click here to pay by credit card.

P.O. or Requisition #

As the conference approaches, you will receive an invoice via postal mail with your confirmation letter.

University Events Coordination requests this information for the sole purpose of Registering you for this program. We do not routinely release any of this information to anyone outside our institution without express permission. We do ask that you fill out all the Registration items that apply to you. We are unable to process forms that do not include your name and address.

The University of Northern Iowa is an equal opportunity educator and employer with a comprehensive plan for affirmative action.

 

Date Updated: February 28, 2012