Conference Registration Form
MSHA Conference Registration Form
The Way Forward...Tried & True and Something NEW: MSHA Annual Conference~March 22-24, 2012
The Radisson Plaza Hotel~Kalamazoo, Michigan
Mail to: MSHA ~790 W. Lake Lansing Rd. Suite 500A~East Lansing, MI 48823
msha@att.net ~ www.michiganspeechhearing.org
Name:______________________________________________Date:______________________
*Early Bird Discount 25% Deadline 3-01-12
Registration Fees:
| Please indicate your selection: | MSHA Member |
|
Non-MSHA Member | Total | ||
| 3 Day Conference Packages: | Early Bird* | After March 1 | Early Bird* | After March 1 | ||
| Deluxe Conference: Thursday Cochlear Workshop, Thursday Evening Short Course, Friday & Saturday Sessions (2.2 CEUs possible) | $240.00 | $300.00 | $330.00 | $410.00 | ||
| Standard Conference: Thursday Short Courses, Friday & Saturday Sessions (2.0 CEUs possible) | $190.00 | $240.00 | $280.00 | $350.00 | ||
| Single Day Packages: Please indicate specific day | ||||||
|
Thursday: Cochlear Implant Workshop and Evening Short Course (0.9 CEUs possible) |
$175.00 | $220.00 | $265.00 | $330.00 | ||
| Thursday: Afternoon & Evening Short Course (0.7 CEUs possible) | $155.00 | $195.00 | $245.00 | $305.00 | ||
| Friday (0.7 CEUs possible) | $155.00 | $195.00 | $245.00 | $305.00 | ||
| Saturday (0.7 CEUs possible) | $155.00 | $195.00 | $245.00 | $305.00 | ||
|
Student Package: |
||||||
| Full Conference Package-Must volunteer to receive this rate. See separate Volunteer Form. Please indicate below if you would like to attend the Cochlear Implant Workshop. | $20.00 | $20.00 | ||||
| Guest Package: | ||||||
|
Includes Receptions and Refreshment Break. Name:______________________ |
$25.00 | $30.00 |
Meals: You must pre-register for all meals!
| Fridays Awards Lunch: | $25.00 Regular___Vegetarian___ | Quantity____ | Amount: $ |
| Sat Public School Forum Lunch | $25.00 Regular___Vegetarian___ | Quantity____ | Amount: $ |
| Sat Medical SLP Forum Lunch | $25.00 Regular___Vegetarian___ | Quantity____ | Amount: $ |
Short Courses: Plese check or circle your choices. Therse are Short Courses only-all 1 and 2
hours sessions do not require pre-registration (see Preliminary Program). Unreserved short course
tickets will be available on-site.
|
Thursday Morning Cochlear Implant Workshop 8:15 am-3:00 pm
____Cochlear Implant Workshop by the University of Michigan Cochlear Implant Team. |
Thursday Evening: 6:00-9:15 pm ____Angela Hein Ciccia: Best Practices for Inpatient & Outpatient Rehab for Adolescents & Adults with Acquired TBI ____Carol Flexer: Auditory Brain Development: The Key to Listening, Language and Literacy |
Friday Morning: 8:30-11:45 am ____Michelle Bourgeois: Beyond Memory Books... ____Karen Florka: Intro to the Communication Matrix... ____Colin Macpherson: Communication Assessment & Intervention Strategies...
|
Saturday Morning: 8:30-11:45 am ____James Coyle: Treatment of Dysphagia... ____Keli Richmond: Simultaneously Improve Speech Intelligiblility... ____Teresa Ukrainetz: Narrative Intervention: Episodic... |
|
Thursday Afternoon 1:00-4:15 pm ____Counseling & Ethics, Managing Caseloads and Difficult Conversations. |
Friday Afternoon: 1:30-4:45 pm ____Carol Flexer: Theory of Mind Development in Children... ____Kristin Chmela: Basic Principle Problem Solving in School-Age Stuttering Therapy |
Saturday Afternoon: 1:30-4:45 pm ____Teresa Ukrainetz: Expository Intervention: Teaching How... ____Ellayne Ganzfried: Tools for Aphasia Advocacy... |
Name:________________________________________________________________________
Affilation/Work Place (for Badge):___________________________________________________
Address:_______________________________________________________________________
City/Zip:________________________________________________________________________
Email Address:__________________________________________________________________
| __SLP | __AUD | __Teacher of the Deaf/Hard of Hearing | __Grad Student | __Undergrad | __Other |
CEUs:
| ____Yes, I want CEUs | ____I already paid my $10.00 MSHA CEU Fee | ____Here is my $10.00 MSHA CEU fee | $ |
MSHA Membership Dues:
| ____I already paid my 2012 MSHA dues |
____Here are my 2012 dues. $70.00 Active; &60.00 Associate; $15.00 Affiliate; $30.00 Student; $15.00 Advocate. See the MSHA Memberhip Form for info. |
$ |
Payment Method:
Total Amount:__________________________ My check is enclosed_______ OR:
Visa #________________________________________________________________
MasterCard #__________________________________________________________
Discover #____________________________________________________________
Expiration Date:_______________________________Card Holder's Name_______________________________
Authorized Signature____________________________________________________
Please note: A $25.00 Service Charge will be deducted for refunds requested on or before March 15, 2012.
No refunds will be granted after March 15, 2012.
Mail to: MSHA~790 W. Lake Lansing Rd. Suite 500-A~East Lansing, MI 48823~FAX 517-332-5870~Phone 517-332-5691
Hotel Reservations: To receive our group rate, identify yourself as a Michigan Speech-Language- Hearing Association participant. Hotel Reservations can either be mailed directly to The Radisson Hotel, 100 W. Michigan Ave., Kalamazoo, MI 49007 Or you can register by phone at 1-269-343-3333 or 1-800-333-3333 (Code MSHA12) or you can register on-line at www.radissonkz.com by March 1, 2012. Use our Group Code: MSHA12. After that date, or should the Group Block be filled before then, rooms will be reserved based upon availability.
See MSHA Hotel Reservation Form for the Radisson Hotel in Kalamazoo, Michigan.
Thank you. You will receive an email confirmation from MSHA. A registration folder with tickets, receipt, badge, etc., will be ready for you at the MSHA Registration Desk at the conference. If you have questions or wish to confirm your registration, call MSHA at 517/332-5691.
This conference is offered for a maximum of 2.2 CEUs at Intermediate Levels in Professional Areas. MSHA is approved to sponsor State Board Continuing Education Units (SB-CEUs) through the Mich. Dept. of Education. Participants at the MSHA Conference may earn a minimum of .5 or a maximum of 2.2 CEUs.
Thank you! Recommendations/Suggestions for future conferences: