2003 Registration form

First Name*			Last Name*
Badge name

Address	City	State	Zip
Phone*	Fax	Email*

Special Needs

Please check all that apply:
	I am interested in volunteering at the conference. Please call me.
	I am requesting continuing education credits (CEU's and CME's) at the conference.
	I would like to make a donation to cover costs of survivors unable to pay (see below).
	Call me about sponsorship/exhibitor opportunities.

Conference Registration Fees:
Registration fees include continental breakfast and dinner on Friday; lunch on Friday and Saturday; all conference related materials, continuing medical/educational units; and access to all conference sessions, exhibits, posters and roundtables.
BIAOR Member***
Non-Member
* Courtesy: Courtesy rate is for brain injury survivors with limited means. **Family: Family refers to up to three members of a family, each person pays listed price.
Accompanying Person
Accompanying Person: Registration fee includes continental breakfast, dinner on Friday; lunches and exhibition only. Fee does not include admission to conference sessions.


Membership Fee
(Become a BIAOR member now and receive the discounted registration Fee)

Scholarship Contribution
(donation to assist in covering the cost of survivors with limited funds)


Registration and Membership	Total
(Please add totals from Registration Fee, Membership Fee and Scholarship Contribution for final total costs)


* Courtesy rate is for brain injury survivors with limited means.
*** A limited number of conference scholarships are available to survivor members of BIAOR to cover the costs of conference registration. For more information, contact the BIAOR office: 503-413-7707

Payment
Payment in full must accompany your registration. Payment may be made by check or money order (use pdf registration form), PayPal (see directions below), or VISA or MasterCard.
Amount to be charged $	VISA MasterCard	Check in the Mail
Name on Credit Card	Account #	Expiration Date

PayPal (the internet bank) has been activated to receive credit card payments. To use this service, log onto www.PayPal.com and follow these simple steps: Set up your FREE, SECURE personal PayPal Account Click on Send Money and follow instructions At “Recipient’s Email” address, enter: biaor@biaoregon.org For “Amount” enter the total to be paid by card that you entered on registration form For Type, choose Service Verify transaction Watch for email confirmation For assistance, call Sherry Stock 503-740-3155 Continuing Medical Credits and Continuing Education Credits will be available at the conference


Confirmation and Cancellation Policies
Confirmation letters will be e-mailed within 5 business days of receipt of registration. If your confirmation is not received within 2 weeks, please contact us via e-mail at biaor@biaorgon.org or by telephone at +1-800-800-544-5243 or 503-413-7707, M-F, 9-5. Cancellations must be received in writing by September 26, 2003 to qualify for a refund. A $25.00 administrative fee will be deducted. Substitutions are always welcomed and no-shows will be billed.

Registration, Payment, and Refund Policy
Please submit payment with completed registration form. Fees are payable by check, credit card, or state government purchase orders which obligate payment. All payments must be received by September 15, 2003, to be eligible for discount. All cancellations are subject to a $25 processing fee. No refunds will be issued for cancellations received after September 26; however, registrations are transferable.