Alabama Autism Conference Registration Form
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The University of Alabama
Tuscaloosa, AL 35487
Please submit this entire page for your registration. For multiple registrations, please duplicate this form.
[ ]Mr. [ ]Ms. [ ]Dr. First:____________________________Middle Initial:________Last:____________________________
[ ] Enclosed is a check for $____________________________ made payable to THE UNIVERSITY
[ ] Purchase order is attached.
[ ] Charge $____________________________to credit card: [ ] MasterCard [ ] VISA [ ] American Express [ ] Discover
Card #____________________________Exp. Date (M/Y)____________________________
Security / Verification / CVV Code____________________________(Three or four digit code on back or front of credit card.)
[ ] In-Person Attendance
[ ] Virtual Attendance
[ ] $149 – Early Bird, must register by February 6, 2023
[ ] $199 – Standard rate
[ ] $75 – Student
[ ] $135 – UA Employee
[ ] $135 -Group Rate (Available for companies or organizations sending 3 or more people. Registrations must be submitted at the same time to qualify.)
In-Person Program #CS-2302-AAC001-01
Virtual Program #CS-2302-AAC001-02
Note: The University of Alabama is committed to complying with the Americans with Disabilities Act. Requests for accommodation of physical and/or dietary needs should be made at least 30 calendar days in advance of the program date. Please email your request to email@example.com. A portion of the invoice amount for this program will go to the Capstone Lifelong Learning Foundation to support activities of The University of Alabama and the Office of Teaching Innovation and Digital Education. Need our STAARS Vendor Number? Please use VC000118827 for UA Office of Teaching Innovation and Digital Education.
Questions? Contact Emily Townsend at firstname.lastname@example.org