ALDAcon 2019 Registration THIS FORM IS FOR ONLINE CREDIT CARD REGISTRATION ONLYThis form is for credit card online registration only. If you want to mail a check or money order for registration, download a PDF version of this form HERE . Then print and mail the form with your check. Thank you.Name* First Last Nickname for ID Badge Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* Enter Email Confirm Email Valid e-mail is required.Phone*Phone Type*VoiceText OnlyIs this your first ALDAcon?*YesNoWill you be bringing a hearing service dog?YesNoDog must stay on leash.Are You a Personal Care Attendant?YesNoNo charge for registration, but meals must be purchased. Please fill in name of the registered person you are assisting below. Name of Person You Are Assisting Registration RatesFull registration prices include workshops, exhibits, entertainment, speakers, and the following events: Wednesday Reception, Thursday Lunch, Friday Lunch and Banquet, Saturday Karaoke Party, and Sunday Breakfast.ALDA MEMBER REGISTRATIONSelect OneEarly Bird - February 15 to July 15, 2019 - $310.00Regular July 16 to October. 1, 2019 - $340.00EZ Pay Plan - See belowEZ Pay Plan - Members OnlyMinimum of $50.00 to start, available for members only. Date of start will determine the amount owed. You may pay by periodic installments, or all at once after the initial payment, but balance needs to be paid in full by August 31, 2019. Check EZ Pay Plan in field above and fill in the amount you wish to pay on line below. Apply this amount to Registration: SPOUSE/DOMESTIC PARTNER REGISTRATIONSelect OneEarly Bird - February 15 to July 15, 2019 - $290.00Regular - July 16 to October 1, 2019 - $320.00Only applicable when combined with spouse/domestic partner's full registration.Spouse/Domestic Partner's Name First Last (First name will be shown on ID badge)NON MEMBER REGISTRATIONSelect OneEarly Bird - January. 1 to July 15, 2019 - $340.00Regular - July 16 to October 1, 2019 - $370.00MILITARY VETERAN REGISTRATIONSelect OneOne Rate - Until October 1, 2019 - $260.00SINGLE DAY REGISTRATIONNote: Friday Banquet or Saturday Karaoke Party can be purchased separately below. Thursday or Friday registration includes lunch if registered before 10/1/19. No lunch on Saturday.Select OneOne Day - Thursday - $100.One Day - Friday - $100.One Day - Saturday - $40.0.Two Days - Thursday and Friday - $200.Two Days - Friday and Saturday - $140.Two Days - Thursday and Saturday - $140.Online Registration Closes October 1, 2019 at 11:59PMOn & after 10/2/2019, online registration is CLOSED and you may register onsite only. Onsite registration includes workshops, speakers, and exhibit hall. Price for onsite will be $30.00 higher than regular registration fee, across the board for all full registration Single day onsite registrations will increase by $10.00 per day. No meals are included with onsite registration. Meals can be purchased onsite IF the hotel can accommodate the request. We encourage you to register in advance for the best value.A LA CARTE Meals/EventsPlease specify below the number of ADDITIONAL meal tickets (such as for a non-registered guest, or a single day registration meal/event that is not covered). Please note that all meals are included in a full registration, except for onsite registration. No meals are included with any onsite registration, either full registration or single day. Single day registration meals as noted above. Thursday Luncheon Price: $60.00 Quantity: Friday Luncheon Price: $60.00 Quantity: Friday Night Banquet Price: $80.00 Quantity: Saturday Karaoke Party Price: $40.00 Quantity: Sunday Farewell Breakfast Price: $50.00 Quantity: Optional Museum TourOn Thursday night, we will be touring the Nelson Atkins Art Museum. The tour will be accessible and then everyone can enjoy a night out on your own with fine dining or shopping on the Plaza. The cost covers the chartered bus (to/from the Museum and hotel at the designated times. The Museum tour is FREE. (You are welcome to join us at the Museum if you will be arranging your own transportation.)Optional Museum Tour & Bus Price: $40.00 Quantity: Please fill in quantity (i.e 1) if you wish to reserve a seat on the bus and visit the museum.Museum Tour ChoicesAlso, please check the appropriate boxes below if you are planning to join us for the Museum tour. Will attend Museum tour but no transportation needed ASL Interpreter preferred for tour Captioning preferred for tour JOIN/RENEW MEMBERSHIPSelect OneRegular $30Senior (62 yrs or over) $25.Veteran - $25.Business - $50.Bronze Lifetime - $500.Silver Lifetime - $1500.Gold Lifetime - $3000.Tax Deductible DonationPlease fill in the total amount of donation. (i.e. 50. for 50 dollars.) GRAND TOTALPLEASE NOTE: THIS IS THE AMOUNT THAT WILL BE CHARGED TO YOUR CREDIT CARD. PLEASE BE SURE IT REFLECTS WHAT YOU ARE PAYING FOR.GRAND TOTAL $0.00 Please pay the grand total listed above in full. Method of PaymentThis is for Credit card payments that are processed online only, payable thru Stripe, our preferred online credit processor. Stripe will accept American Express, Visa, MasterCard, or Discover credit cards. Those wishing to pay by check or money order, need to print and fill out the PDF form. ***PLEASE NOTE: GRAND TOTAL ABOVE IS THE AMOUNT YOU WILL BE CHARGED ON YOUR CREDIT CARD. PLEASE MAKE SURE IT IS THE CORRECT AMOUNT YOU WISH TO PAY BEFORE SUBMITTING.***Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Special NeedsAll workshops/events will feature sign language interpreters and CART (Communication Access Real-Time Translation). Workshop rooms will be looped, to assist those with T-coils.Dietary NeedsPlease note any dietary needs or allergies:Special NeedsPlease check if the following special needs are requested: ADA room kit needed Mobility accessible room needed Any other needs ROOMMATE MATCHBy selecting YES below, I agree to allow the ALDAcon roommate coordinator to share my information via email with any ALDA attendee of the same gender. Also I agree to coordinate with my potential roommate to determine if we are a match. We will discuss items such as service animals, allergies, smoking, etc. We will then notify the roommate coordinator by email of our decision after determining if we agree to room together & share expenses. NOTE: All room reservations are the responsibility of the agreed- upon roommates. Do you want a roommate?YESNOI am a:MaleFemaleReserve Your Hotel Room TODAYReserve your hotel room at the Marriott Kansas City Overland Park Hotel in Overland Park, KS today! The ALDAcon room rate is $121.00+ tax, and will be good until October 1, 2019 or until room block is filled. You can call 913-451-8000 to speak with hotel directly. To access the ALDAcon 2019 group rate, please use the reference code: ALDALDR. Online reservations may be made at the following link: HOTELSpecial Note:By submission of this registration form and attendance at the 2019 ALDAcon, you agree that ALDA Inc. may use such photographs or videos taken of you at the convention, with or without your name, for any lawful purpose, including for example such purposes as publicity, promotion, illustration, advertising, and Web or social media content. Refund PolicyRequests for refunds (minus $50.00 handling and processing fee) will be honored until July 31, 2019. No refunds will be given from August 1, 2019 on. Contact ALDAcon 2019 Planning Co-chair (Tina.Childress@gmail.com) for consideration of unique circumstances, such as illness or a death in the family.