32nd Annual CSA Conference
October 30 - November 1, 2009
Registration Form

Print Name:_________________________________________________________________ Date: ______________________

Address:________________________________________________________________________________________________

City:______________________________________________________ State: _________ Zip: __________________________

Telephone (required):________-________-__________ E-mail: ___________________________________________________


Registration
*Full registration includes meals, admission to sessions and exhibit hall, a Conference syllabus as well as one set of speaker recordings per registration address. Additional sets can be ordered below.

To register after 10/12/09, call 877-CSA-4-CSA (877-272-4272). Registration fees increase 30% on 10/13/09.

Photo/Video Statement
By attending this event it is agreed that photos/videos may be taken and used by CSA for promotional and educational purposes.

I have specific dietary needs (Gluten-free meals and snacks)
? Lactose-free ? Vegetarian

Minors
All minors must have a parent or guardian registered as a
conference participant.

Special Assistance
CSA adheres to the articles of Title III of the 1990 Americans
with Disabilities Act. If special assistance is required, notify
CSA by 9/1/09.

I am interested in receiving Educational Credits
? Dietitian: Application for CPE Units will be submitted through the American Dietetic Association’s Commission on Dietetic Registration.
? Nurse: Application for approval of nursing contact hours is being made to the Pennsylvania State Nurses Association, an accredited
approver by the American Nurses Credentialing Center’s Commission
on Accreditation.

Register On/Before 10/12/09 #

 

Registration

First and Last Names Amount
Member Full *   $350.00 x___
Non-Member Full *   $550.00 x___
One Day (Lunch Only) ?Friday
?Saturday
$180.00
$180.00
x___
x___
CSA KidZone
(ages 7-11)
  $125.00 x___
CSA TeenScene (ages12-16)   $125.00 x___
CSA Young Adult (ages 17-21)   $250.00 x___
Historical Tour “Erie”
October 29 9:00 am – 4:00 pm
  $45.00 x___
“Oktoberfest” Buffet
October 29 4:30 pm - 8:30 pm
  $40.00 x___

 

Additional Options

     
Guest Meals      
Friday Breakfast ? $25.00 x___
Friday Lunch ? $25.00 x___
Friday Dinner ? $35.00 x___
Saturday Breakfast ? $25.00 x___
Saturday Lunch ? $25.00 x___
Saturday Dinner ? $40.00 x___
Sunday Breakfast ? $25.00 x___
Speaker Presentation Recording Set $70.00 x___
CSA Membership Renewal
New
$25.00
$33.00
x___
x___

 

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Total $________


Payment method: ? Check: Amount (Payable to the Celiac Support Association) ________________

? Credit card:
Provide
Security Code:

Visa

_______

Discover

_______
MasterCard

_______
American Express

____________

Credit card number:__________________________________________________________ Exp. Date: _______________________

Full name of cardholder (Please Print):___________________________________(Signature):__________________________________

No refunds will be issued once payment has been received. Forfeited fees will be retained as a donation to CSA.
Mail to:
CSA, PO Box 31700
Omaha, NE 68131

 

2009