CONFERENCE REGISTRATION

Who Should Attend the Conference?
Individuals who are living with dementia symptoms and anyone who cares about, works with, interacts with or provides support for them should attend this important conferenceRe-Imagine Life with Dementia will bring together the diverse dementia community for collective discussions, interactions and learning experiences.  All will gain valuable insights and takeaways from the conference.

Registration Type
Your conference registration includes two days of education sessions, the TECHNOLOGY SHOWCASE, Exhibits, Author Book Signings, Sunday evening reception, Monday and Tuesday lunches, afternoon snacks, and educational materials.

Regular Registration – by June 23, 2017
On-Site Registration
Person Living with Dementia Registration
Care Partner Accompanying a Person with Dementia to the Conference Registration
Single Day Registration

Please indicate which day you are attending:
Sponsor/Exhibitor Additional Registrant

Please mark your selected registration fee.

Registration Code
If you have received a registration code, please enter your code here . The appropriate price will appear below.


Please complete one registration form for each person who will attend the conference.
 

Indicates required field
First Name:
Last Name:
First Name or Nick Name for Badge:
Affiliation (if any):
Title (if any):
Email:
Confirm Email:
Street Address:
City:
State/Province:
Zip Code:
Country (if other than U.S.):
Phone Number:

Please check one area below that most applies to you –
Person living with dementia Care partner
Academic/Educator Adult day services
Advocacy entity Assisted living/Personal care home
CCRC Community organizer
Federal agency Home care/Home health care
Memory Café organizer Nursing home/Skilled Care
Researcher Sponsor/Exhibitor
State agency Student
Technology company Other (please list)

Food Accommodation Requests
Vegetarian meal Gluten-free meal
Vegan meal Food Allergies (please list)

Special Needs Requests
Visual limitations Hearing limitations

Special Interest Groups
Please select the group category you would be most interested in -
Adaptive Technology Optimizing Well-Being
Advocacy & Changing the Status Quo Care Partnering
Living with Dementia Creative Arts
Best Practices Community Organizing

Registration Cancellation Policy – All registration cancellation requests must be made in writing to 424 General Early Drive, Harpers Ferry, WV 25425.  There will be a $100.00 processing fee for each refund.  No registration refunds will be made after June 12, 2017.

Participant substitutions may be made without penalty any time prior to the conference. Requests may be submitted to registrar@OPTPlanning.com, faxed to 304-566-9911 or mailed to 424 General Early Drive, Harpers Ferry, WV 25425.

NOTE - Registrants are responsible for cancelling their hotel reservations.

CONTINUING EDUCATION UNITS
Please let us know which CEUs you will apply for, so we may provide any special paperwork needed. Each registration includes processing of one individual's CEU application.
CEUs for License #(s) State(s)
Nurses: RN or LPN
Administrators
Social Workers
 

Registration Payment
Payment for the conference can be made by MasterCard, Visa, Discover or U.S. check.

IF PAYING BY CHECK, please print the completed form and mail the form and check to – 
Dementia Action Alliance
424 General Early Drive
Harpers Ferry, WV 25425

Please make checks payable to the Dementia Action Alliance

 

Your registration will not be processed
without full payment.

Total Due:
Please check one:
First Name of Cardholder:
Last Name of Cardholder:
Card Number:
Expiration Date: Month: (mm) Year: (yy)
Security Code:
Card Billing Address:
Address:
City:
State:
Zip:
By submitting this form, you are authorizing the Dementia Action Alliance to process your credit card for payment as indicated above.  Conference badges and on-site materials will be provided to you at the on-site conference registration area.


 

If you have questions regarding your registration, please phone 681-252-3570 or e-mail registrar@OPTPlanning.com.

Photo Release
We use photos for social media and other awareness efforts of the Dementia Action Alliance. Your attendance at the conference provides the Dementia Action Alliance the right to use your likeness for such materials.