Thank you for your interest in the DBSA 2013 National Conference: Stronger Together being held this coming June 14-16, 2013 in Miami, Florida! To register for the conference, you must complete the form below and, at the end, click the button labeled "CONTINUE TO REGISTRATION" to enter the Google Checkout ticketing system and complete your purchase.
* Denotes required fields
1.
Name of Attendee
2.
Question - Not Required -
Name on Credit Card (IF different from Name of Attendee):
3.
Question - Not Required -
Special Dietary Restrictions
4.
Question - Not Required -
Special Accessibility/Accommodation Needs**
5.
Question - Not Required -
Emergency Contact
6.
Question - Not Required -
Emergency Contact Phone
7.
Question - Not Required -
Organization
8.
Question - Not Required -
How did you hear about the conference?
IF you are a DBSA Chapter/Support Group participant, the following information is required. Otherwise you may skip questions 9-11.
9.
Question - Not Required -
Chapter/Support Group Name
10.
Question - Not Required -
Chapter/Support Group City
11.
Question - Not Required -
Chapter/Support Group State
12.
Question - Not Required -
I give DBSA permission to share my name, chapter and email address with other CLF participants.
Please select response
Yes
No
If you are the only participant, you may skip to the bottom of this page and click "CONTINUTE TO REGISTRATION."
If you are registering multiple individuals within the same order, their contact information is required. Otherwise, you may skip questions 12-21.
13.
Question - Not Required -
(1) Additional Participant Name:
14.
Question - Not Required -
Does Additional Participant (1) have the same contact information?
Please select response
Yes
No
15.
Question - Not Required -
If contact information differs, please list the Additional Participant's (1): Email, Phone, Mailing Address, Special Diet/Needs**, Emergency Contact & Phone, Chapter/Support Group Name/City/State:
(Maximum response 255 chars, approx. 5 rows of text)
16.
Question - Not Required -
(2) Additional Participant Name:
17.
Question - Not Required -
Does Additional Participant (2) have the same contact information?
Please select response
Yes
No
18.
Question - Not Required -
If contact information differs, please list the Additional Participant's (2): Email, Phone, Mailing Address, Special Diet/Needs**, Emergency Contact & Phone, Chapter/Support Group Name/City/State:
(Maximum response 255 chars, approx. 5 rows of text)
19.
Question - Not Required -
(3) Additional Participant Name:
20.
Question - Not Required -
Does Additional Participant (3) have the same contact information?
Please select response
Yes
No
21.
Question - Not Required -
If contact information differs, please list the Additional Participant's (3): Email, Phone, Mailing Address, Special Diet/Needs**, Emergency Contact & Phone, Chapter/Support Group Name/City/State:
(Maximum response 255 chars, approx. 5 rows of text)
22.
Question - Not Required -
Purchasing Multiple Tickets Information. Please clarify which attendee is attending which event. For example, Mary might register for the full conference Friends Reception, but Ted is registering for full conference and pre-conference Family Institute. Clarify if necessary:
(Maximum response 255 chars, approx. 5 rows of text)
NOTES:
**Individuals MUST indicate on this form any special accessibility or accommodation needs they require so that DBSA can provide the appropriate resources. We request that individuals provide a minimum of one month’s notice (May 14, 2013) so that we can ensure that resources are available and that they can be secured at a reasonable rate.
You will NOT receive a confirmation letter or tickets in the mail. T he e-mail confirmation you receive from Google Checkout serves as the ONLY confirmation of your registration for the DBSA 2013 National Conference. PLEASE KEEP A COPY FOR YOUR RECORDS.
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