Printable Registration Form

Printable form – Use your browser’s Print icon to print

Please submit this entire page for your registration. For multiple registrations, please duplicate this form.

[ ]Mr. [ ]Ms. [ ]Dr. First:____________________________Middle Initial:________Last:____________________________

Preferred Name/Nickname:____________________________

Company/Organization Name:____________________________

Mailing Address:____________________________City:____________________________State:________Zip:______________

Email Address:____________________________Phone:____________________________

Job Title:____________________________

[ ] Enclosed is a check for $____________________________ made payable to THE UNIVERSITY OF ALABAMA

[ ] 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.)

Authorizing Signature:____________________________

Event Type:

[  ]  Virtual attendance Online (Program # CS-2403-DSWCON-01)

Registration Fee:

[  ]  $25 Professional Registration

[  ]  $15  Student Rate

[  ]  $200 – Silver Sponsorship (Includes participant contact list and logo on conference materials)

[  ]  $300 – Gold Sponsorship (Includes participant contact list, logo on conference materials, and virtual conference booth)

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 professionaldevelopment@ua.edu. 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 College of Office of Teaching Innovation and Digital Education.

Questions? Contact Melissa Duggan at 205-348-8528 or email professionaldevelopment@ua.edu.