Registration Form w/ Credit Card

2023 Conference Registration & Credit Card Payment w/ Square

Registration – Deadline is 4/25/2023

To Register for the Conference and pay with a credit card, you must complete the registration form below for each individual attending. Online credit card payment includes a $8 credit card convenience fee. If bringing a non-registered guest(s), be sure to make selections for additional meals below. Fees are non-refundable for no-shows unless cancelled by Tuesday, April 25, 2023.

"*" indicates required fields

County*

Agency Name*

Name*

First Last

Job Title*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Extension

Choose a Group

Registration Fees (includes all breaks/meals for the day you register):

Full Conference – Tuesday, Wednesday, Thursday - $225 + $8 Credit Card Convenience Fee

Two-Day Conference – Tuesday & Wednesday - $190 + $8 Credit Card Convenience Fee

Two-Day Conference – Wednesday & Thursday - $190 + $8 Credit Card Convenience Fee

Add-On Meal Rates (for non-registered conference guests only)

Banquet – Tuesday Evening

Breakfast – Wednesday

Lunch – Wednesday

Breakfast – Thursday

Total

Secure Credit Card Payment w/ Square

Cardholder Name

Card Details

Phone

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