Last Name:
	to have the computer fill in part of the form for you, knowing only the first few letters of your last name.
Rest of name:	Prof. Dr. Mr. Mrs. Ms. Jr. II III IV First and M.I.
Name for Badge:
Title:
Affiliation:
Mailing Address:
City / State / Zip:
Office Phone:
E-mail:
Name of Guest:
Guest Badge Name:
If the person submitting this form is not the registrant named above . . .
Submitted by:
Submitter e-mail:

Extra instructions or comments for the ECEDHA office staff:

Registration Fees

Registration for the ECEDHA Annual Meeting . . . . . . . . . . . . $540.00

Spouse / guest registration ($200). . . . . . . . . . . . . individual (entry should be 1 or 0)

Additional guest registration ($150/person). . . . . . . . . . . . . individual(s)

Note: Additional guests, including children, (beyond participant and 1 guest) can be registered for the Guest Program at a reduced fee of $150 per person.

Total registration fee ($540 for the registrant plus $200 for first guest and $150 for other guests): $

Instructions

You may register any of the following ways:

• On-line: use the button below; an invoice will be sent to you
• Mail: print this form and mail it to the address below with your payment
• Fax: print this form and fax it to the number below; an invoice will be sent to you

Upon receipt of your registration, the ECEDHA office will mail an invoice to you.  Checks may be sent to the ECEDHA office at the address above or credit card payments can be made by calling 312-559-3724 to ensure security.  We do not have secure online credit card processing at this time.