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Registration Form
| 34th Annual QLA Conference-Registration Form | ||||||||
| August 22-24, 2019 Knoxville, Tennessee | ||||||||
| Hilton Knoxville | ||||||||
| 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. | ||||||||
| 1739 University Ave, #295 | ||||||||
| Oxford, MS 38655 | ||||||||
| 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. | ||||||||