Conference Registration Form/Fees

Registration Form

7th Annual Midwest Conference on Problem Gamblingand Substance Abuse

Roads to Recovery

July 28-30, 2010  HyattRegencyCrownCenter  Kansas City, Missouri

On-site only registration available after July 10th. After July 10th, do not mail or fax to ACT Missouri.

Only cash, check, money order or credit card will be accepted for on-site payment.Registration is complete when the form and fees are received by ACT Missouri.

Space is limited and registration will be accepted on a first received basis. Online registration is available at (NOTE: Online registration is available for credit card payment only.)

Early Bird Deadline: June 15, 2010 Early Bird Regular Onsite

(before 6-15-10)(on/after6-16-10)(on/after 7-10-10)

Friday Afternoon Post-Conference Ethics Training1 $ 30 $ 40 $ 50

Conference Registration2 $195 $225 $270

Student3/ Poster Presenters2, 3(pre-registration required) $ 98 $112 $135

Sponsor / Lead Presenter2, 4(pre-registration required) $ n/a $ n/a $n/a

Thursday Evening Dinner & Theatre at the American Heartland Theatre $ 25 $ 25 $ 50

Guest for Thursday Evening Dinner &Theatre $ 25 $ 25 $ 50

Additional Meal Package / Guest (conference meals only) $175 $200 $225

Total Amount Enclosed$ ______

1 The Ethics training will be held the afternoon of Friday, July 30; it will include 3 hours of training and one snack break.

2Conference includes 2.5 days of training, Welcome Reception, 5snack breaks, 3breakfasts, 2 lunches.

3 Students mustsubmit proof of current enrollment and copy of Student ID. Contact or 573-694-4070with any questions.

4Per the Call for Papers, the Midwest Consortium provides the lead presenter with a complimentary registration; all other presenters must register at the appropriate Early Bird Registration rate (may use student rate, if applicable).

Exhibitors

Exhibitors must complete the exhibitor application, which is also available online. Non-profit and for-profit rates are available, as well as discounted combination rates (with 1 full registration). Exhibit Hall Contacts: r 573-694-4070.

Registrant Information:

Organization Name

Name Guest name

Address

City State Zip Country

Phone Fax E-mail

Special Needs: (Check all that apply)

Dietary (please specify ): Vegetarian Low Sodium Diabetic

Hearing Impaired:

Mobility:

Please select payment method

❑Cash ❑Money Order ❑Credit Card ❑Purchase Order ❑Check #______(payable to ACT Missouri)

Credit Card Type: ❑Visa ❑MasterCard ❑Discover

Credit Card# _ _ _ _ - _ _ _ _ - _ _ _ _ - _ _ _ _ 3 Digit Security Code _ _ _ Exp ___ / ___

Name on Card ______Credit Card Billing Address ______

“I authorize a charge against my credit card in the followingamount $______.”

Signature______E-mail______(For receipt purposes only)

•Fax registration and payment to: 573-635-7257; For further information on registration contact: (573) 635-6669

• Mail registration and payment to:

Katrina Wieberg, ACT Missouri, ATTN: 2010Midwest Conference, 428 E. Capitol, 2nd Floor, Jefferson City, MO65101

CANCELLATION POLICY: All cancellations must be in writing. Cancellations postmarked prior to June 25, 2010 will be refunded less a $50 processing fee. No refunds will be issued if postmarked after June 25th. No Exceptions. If the conference is cancelled for any reason, theliability of the Midwest Consortium on Problem Gambling and Substance Abuse to the registrant is limited to the return of registration fees.

Hotel Information:

Rooms are available at the HyattRegencyCrownCenter(2345 McGee St in Kansas City) at a rate of $124per night (single before June 25). Reservations can be made directly with the hotel 816-421-1234, 800-233-1234, or on Hyatt.com; the conference code is “G-MCPG."

Group lodging rate includes the following concessions: complimentary self-parking (in-the attached garage) for 1 car per guest room, and complimentary access to the hotel’s health club facilities.