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TWO EASY WAYS TO REGISTER!
CONFERENCE
REGISTRATION
By mail:
IMPACT
125 W.Market St.Suite 100
Indianapolis,IN 46204
By fax:
(317)237-6206
HOTEL RESERVATIONS
DoubleTree by Hilton
Lawrenceburg,Indiana
51 Walnut Street
Lawrenceburg,IN 47025
Hotel Rate:$114
Aim Room Block
Book by phone:(8 12)539-8888
Deadline for hotel registration is:
September 6,2017
Deadline for conference registration
Is:September 13,2017
2017 IMPACT ANNUAL CONFERENCE REGISTRATION FORM
Your Information Method of Payment
Name 5 S�t � e R I �; �; (Circle One) Check MasterCard Visa Discover American Express
City/company C U F p,q�, yl -Z Check Number
Tide o� ,—R A TCS. Card Number
Address C//-t/1c- S'Q(,,-%4ec Expiration Date
Cky/rown C'A-12 m L--L— Verification Code
State Name of Cardholder
Zip -; Authorized Signature
Phone '31 -7 25-21 244-5-' Billing Address of dWerent from above)
Email 5P:5P&Li3fO it ' 111 if— //v- .CV City
Email Ashley Spurgeon at aspurgeor,"mindiana org with dietary or allergy concerns. State
Zip
PARegistration Fee for 2017 IMPACT Annual Conference
Ili$200-Full 2017 IMPACT Annual Conference(IMPACT Member)
O$250-Full 2017 IMPACT Annual Conference(Non-IMPACT Member)
77 1 O$150-One Day Rate(Designate a Day.Sep.20,21,or M.
O I would be Interested in attending an after-hours event on Sep.20 at no extra fee.