Conference Registration Form and Payment

Conference Registration Form and Payment2018-05-23T23:34:09+00:00

Registration Options

Registration Payment

MEMBER OR NON-MEMBER PRICING

Registration Form

33rd Annual QLA Conference-Registration Form
September 6-8, 2018 Clearwater, Florida
Marriott All Suites, Sand Key
Name(s) of Attendee(s):
Street Address
City, State, Zip
Phone
Email Address
  Please list all names of attendees
Is this your first time to attend conference? Yes or No
Number of Attendees:  Conference
Members $90 each
Non-Member $100 each
Total to submit to QLA __________________________
Number who will attend the following:
Thursday Reception
Friday Breakfast
Friday Luncheon
Saturday Breakfast
Saturday Luncheon
Saturday Dinner
Mail Checks and Registration Forms to:
Quality Life Association, Inc.
4327 S. Hwy 27, #417
Clermont, FL 34711
Credit Card Information:
Type of Card (Visa, Mastercard or AMEX) ______________
Card Number _______________________________________
Security Code ________________
Expiration date ________________
Billing address if different from above
_______________________________________
_______________________________________
_______________________________________
Amount to be charged: _________________________
(Registrations for Conference only after August 15th subject to Late fee $10)
I agree to have my name, address, phone and email shared with other registrants at
this conference_______________________________________     or
I prefer to not have my information shared__________________________________
Consent to Use Photographic Images
I understand that I may be the subject of photographs or videos that will be taken during
this meeting, and that they will be included into QLA’s stock files.  I agree that photographs
or videos shall be the sole property of QLA, with full right of lawful disposition in any manner.
By registering for this conference, I hereby grant QLA permission to photograph or video
record me during activities and to use the photographs or videos in QLA audio-visual and printed
materials without compensation or approval rights.