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Brain Injury Association of Montana

2006 Conference Registration Form

First Name

Last Name

Business

Address

City

State

Zip

Email address

Telephone

Registration Category:

Individual (Member) $65
Individual (Non-member) $115

Professional (Member) $150
Professional (Non-member) $225
(Professional group rates: 3+ people 10% off)

Please list your profession



Family Package (Member) $150
Family Package (Non-member) $190
(Family package: 3 members of the same family)

Food Choice (be sure to check one or the other, if neither is checked we will assume that you want regular meals versus vegetarian):

Regular
Vegetarian

Registration fee includes conference attendance, two buffet breakfasts, two lunches, snacks, and Friday evening social hour with a no host bar. Friday dinner is on your own. A limited menu in house dinner is available Friday night for an additional $12.

Yes, I want the in hotel meal and will enclose my $12.

$ Total Amount Due

To register online, click the "Submit" button.

To register by mail, fill out and print this form, send it and your check to:
Brain Injury Association of Montana
1280 S. 3rd. Street West, Suite 4
Missoula, MT 59801


 

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