REGISTRATION Two options 1. Print and fill out form and send with check payment Registration Form PDF 2. Fill out form below and choose payment option CAPTASA 2025 Conference Registration Form CAPTASA 2025 Conference Registration Form January 24-25, 2025 Embassy Suites - Lexington, KY Contact Name * First Last * Last Attendee Name Same as Contact Name Different Attendee Name Attendee Name First First Last Last Profession/Credentials Name for Nametag * Institution/Organization Mailing Address * City * State * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip * Phone Fax Email * Please list any special needs you may have (dietary, etc.): I will attend * In Person Online Payment Information • Cost of Banquet NOT included in registration fee.• No one day, group rate or scholarships NO REFUNDS AFTER JANUARY 21, 2025 $300 Early Registration Fee (early registration ends January 5th, 2025) $350 Registration Fee (after January 5th, 2025) I plan to attend the banquet Friday night (cost $35) * Yes No # of guests @ $35 per ticket - Do not include yourself in this count. * # of Handouts @ $35 per set * MUST PRE-ORDER BY JANUARY 17 - NOT AVAILABLE FOR PURCHASE AT CONFERENCE - Handouts will be available online @ www.captasa.org for no charge. FOR EXPRESS REGISTRATION AT THE CONFERENCE: Print your receipt and bring it with you when you register in Lexington. Total Pay Now If you are human, leave this field blank.
