Annual Conference Application

THE KENTUCKY OCCUPATIONAL THERAPY ASSOCIATION
Annual Conference

Sailing to Success

September 28th And 29th, 2007
Pre-Conference Sessions September 27th

The Center for Rural Development
2292 South Highway 27
Somerset, KY 42501

PERSONAL INFORMATION

Last Name:      First Name:

  Address:

     City:     State:     Zip:

Contact Phone:

E-Mail Address:
(Conference confirmation will be sent to this email)

Organization/Facility:

Registration Fee Table

Type	Member	Non-Member	Student Member	Student Non-Member
2 Day Conference
OT/OTA	$175.00	$275.00	$40.00	$75.00
2 Day Early Registration (due 8/31)
OT/OTA	$157.50	$247.50	$36.00	$67.50
1 Day Only
OT/OTA	$100.00	$170.00	$25.00	$50.00
Other Rates
Consumer	$25.00	Daily rate, no continuing education credit given, includes Rehab Techs
Exhibit Hall Pass Only	$10.00

If attending for one day only, please indicate which day: 9/28     9/29

PAYMENT INFORMATION

Conference Registration Fee: (Use the above lookup table to determine your fee)	$
PRE-CONFERENCE SEMINAR: Dr. Winnie Dunn, The Sensory Profile School Companion $100 members, $175 nonmembers, $50 Student Members	$
PRE-CONFERENCE SEMINAR: Dr. Surya Shah, Stroke Rehabilitation $100 members, $175 nonmembers, $50 Student Members	$
Lunch With a Scholar ($29.00, will be charged separately on your credit card):	$
Total Amount to Charge:	$

(MasterCard or Visa accepted)

Cardholder Name:

Card Number:

Expiration Date (month/year):

Card Billing Address:

There are no charges to attend the annual business meeting and the auction. Checks should be made out to KOTA. *KOTA offers reciprocity for members in other State associations to attend the Conference at member rates; Presenters get a 10% discount for conference; No shared registration; or substitutions. Cancellations must be submitted in writing; $25.00 charge for cancellations; Questions: call KOTA at 1.888.987.5682, or email: rhondatedwards@prodigy.net; register online at www.kotaweb.org or mail registration to: KOTA Conference, PO Box 21502, Louisville, KY 40255