apse banner youtube icon linked in icon twitter icon facebook icon
About APSE Foundation Employers Chapters Publications Training Public Policy Certification Jobs Join APSE

2012 National APSE Conference Registration Form

First name:

Last name:

Job title:

Agency:

Address 1:

Address 2:

City:

State:

Zip:

Country:

Phone:

Fax:

Email:


Web site:


APSE membership #:

If you are registering as a non-member, please leave this field blank.

Members, if you do not know your membership number, you can have it emailed to you.


Would you like to add your name to the list of registrants who are looking for a roommate at the conference?

Yes
No


Please check the option that best describes you:

Job Coach / Job Developer
Agency Director
K-12 Educator
University Staff / Researcher
Employer
Family Member
Individual with a Disability
State Agency Personnel
Other    (please specify: )


How did you hear about this conference?

APSE web site
Internet search engine
Conference registration flyer
Save the Date card
Email
At a conference    (please specify: )
Co-worker / friend / employer
Facebook
Twitter
LinkedIn
Other    (please specify: )


Please tell us if you have any disability-related accommodation needs (e.g. sign language interpretation, Braille or large-print materials, etc.). All requests must be made by May 1, 2012.

Please tell us if you have any special dietary needs that we should know about as we plan coffee breaks, receptions, etc. All requests must be made by May 1, 2012.

Conference Fees Schedule

Conference Registration Fees Early Rate

Payment due on or before

Mar. 30, 2012 		Regular Rate

Payment due on or before

June 1, 2012 		Late Rate

Payment on-site or after

June 1, 2012
APSE MEMBER      
Individual Fee $340.00 $385.00 $430.00
Students with ID $175.00 $200.00 $225.00
Family Members / Individuals with Disabilities $170.00 $190.00 $210.00
NON-MEMBER      
Individual Fee $490.00 $535.00 $580.00
Students with ID $200.00 $225.00 $250.00
Family Members / Individuals with Disabilities $200.00 $225.00 $250.00

Please Note: Individual rates are intended for anyone who works in the supported employment, rehabilitation, or related fields.

Participant Rate

Please choose the option that best describes you.

Individual, APSE member ($340)
Individual, APSE non-member ($490)
Student with ID, APSE member ($175)
Student with ID, APSE non-member ($200)
Family Member / Individual with a Disability, APSE member ($170)
Family Member / Individual with a Disability, APSE non-member ($200)


Awards Luncheon: Thursday, June 28

   I will attend the luncheon on Thursday, June 28, included in registration fee.

You may also bring guests to the awards luncheon for $40 per person.

Number of guests I am bringing

   Vegetarian meal requested.


APSE Membership Breakfast: Friday, June 29

   I will attend the APSE membership breakfast on Friday morning, June 29, included in registration fee.



APSE Federal ID: 54-1470501

For more information:
Jenny Levet at 301-279-0060.

416 Hungerford Drive, Suite 418     Rockville, MD 20850   |    Phone: 301.279.0060   |    Fax: 301.279.0075   |    Contact Us