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2005 Conference Registration Form

REGISTER AND PAY ONLINE AND SAVE $10

Unleashing the Power of Youth and Community Potential
October 16-18, 2005
Holiday Inn - Allentown, Pennsylvania

Registration Fees: Online payment rates reflect a $10 discount from the fee listed below.
Rates for youth under age 23 are 50 percent off. Online Payment Options - Costs (details)

New for 2005! Register five or more people at the same time and receive a 10% discount. (If you have more than 5 registrations and want to pay with a credit card, please call our office at 215.538.4796. If you are not paying with a credit card please indicate in the comments section you would like to receive the 10% discount for 5 or more registrations.)

Adult rates are:

EARLY BIRD RATE EXPIRED	REGULAR RATE by 9/21/05 EXPIRED	LATE RATE after 9/21/05
ALL THREE DAYS - $270	ALL THREE DAYS - $300	ALL THREE DAYS - $330
TWO DAYS - $240	TWO DAYS - $270	TWO DAYS - $300
ONE DAY - $115	ONE DAY - $145	ONE DAY - $175

Note: A map will be mailed upon receipt of registration. Cancellations will be accepted within 2 weeks of event (less $65 administrative fee). Substitutions welcome. Lunch, breaks, materials included for all attendees.

REGISTRATION FORM

First and Last Name:

Email:

Agency/District:

Address:

City:

State:

Country
(if outside U.S.)

Zip/Postal Code:

Phone:

Fax:

Registration Type:

ADULT YOUTH

Please indicate which day(s):

ALL THREE DAYS
TWO DAYS
ONE DAY

Which day(s) will you attend?
(please check all that apply)

Sunday, Oct. 16

Monday, Oct. 17

Tuesday, Oct. 18

Workshops/Institutes - Workshop Guide

Please indicate which institutes or workshops you will be attending (note: attending an institute takes the place of TWO workshop sessions). Click "workshop guide" above to view descriptions in a new window.

SUNDAY	WORKSHOPS or	INSTITUTES
Session One	1 2 3 4	A B
Session Two	5 6 7 8
MONDAY
Session Three	9 10 11 12	C D
Session Four	13 14 15 16
TUESDAY
Session Five	17 18 19 20
	21 22

* A small fee will be assessed to YMCA employees selecting these workshops.

Payment Information

Online payment instructions will follow your submission of this form.

Check or Purchase Order Number:

Comments: (optional for special needs or instructions)

2005 Conference Registration Form

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