{"id":364,"date":"2021-10-22T20:51:55","date_gmt":"2021-10-22T20:51:55","guid":{"rendered":"https:\/\/ccswpms01.ua.edu\/adhd\/?page_id=364"},"modified":"2025-09-05T21:25:50","modified_gmt":"2025-09-05T21:25:50","slug":"register-by-mail","status":"publish","type":"page","link":"https:\/\/ccswpms01.ua.edu\/adhd\/register-by-mail\/","title":{"rendered":"Register by Mail"},"content":{"rendered":"

ADHD Conference Registration Form<\/h2>\n
This form is printable – Use your browser’s “Print” icon or the “Print this page” button to print it. <\/div> \n

Mail To:<\/h3>\n

Registration Services<\/strong>
\nThe University of Alabama<\/strong>
\nBox 870388<\/strong>
\nTuscaloosa, AL 35487<\/strong><\/p>\n

Please submit this entire page for your registration. For multiple registrations, please duplicate this form.<\/p>\n

[ ]Mr. [ ]Ms. [ ]Dr. First:____________________________Middle Initial:________Last:____________________________<\/p>\n

Preferred Name\/Nickname:____________________________<\/p>\n

Company\/Organization Name:____________________________<\/p>\n

Mailing Address:____________________________City:____________________________State:________Zip:______________<\/p>\n

Email Address:____________________________Phone:____________________________<\/p>\n

Job Title:____________________________<\/p>\n

[\u00a0 ] Enclosed is a check for $____________________________ made payable to THE UNIVERSITY
\nOF ALABAMA<\/p>\n

[\u00a0 ] Purchase order is attached.<\/p>\n

[\u00a0 ] Charge $____________________________to credit card: [\u00a0 ] MasterCard [\u00a0 ] VISA [\u00a0 ] American Express [\u00a0 ] Discover<\/p>\n

Card #____________________________Exp. Date (M\/Y)____________________________<\/p>\n

Security \/ Verification \/ CVV Code____________________________(Three or four digit code on back or front of credit card.)<\/p>\n

Authorizing Signature:____________________________<\/p>\n

Registration Fee:<\/h3>\n

[\u00a0 ] Early Bird: $149.00 (Must register by January 3, 2025)<\/p>\n

[\u00a0 ] Standard: $199.00 (Begins January 10, 2025)<\/p>\n

[\u00a0 ] Three or More from the same organization: $135.00 (must register at the same time)<\/p>\n

[\u00a0 ] UA Employee: $135.00<\/p>\n

[\u00a0 ] Student: $75.00<\/p>\n

[\u00a0 ] IN-Person Attendance Preference<\/p>\n

[\u00a0 ] Online Attendance Preference<\/p>\n

Program #:
\nCS-2501-ADHD01-01 (In-Person)
\nCS-2501-ADHDV-01 (Online)<\/p>\n

Do you have any dietary restrictions? [ Yes ]\u00a0 [ No ]<\/p>\n

Do you have any accommodation needs? [ Yes ]\u00a0 [ No ]<\/p>\n

Note: The University of Alabama is committed to complying with the Americans with Disabilities Act. Requests for accommodation of physical and\/or dietary needs should be made at least 30 calendar days in advance of the program date. Please email your request to ehtownsend@ua.edu<\/a>.<\/p>\n

Need our STAARS Vendor Number? Please use VC000118827 for UA Office of Teaching Innovation and Digital Education.<\/p>\n

A portion of the invoice amount for this program will go to the Capstone Lifelong Learning Foundation to support activities of The University of Alabama and the Office of Teaching Innovation and Digital Education.<\/p>\n

Questions? Contact Emily Townsend at ehtownsend@ua.edu<\/a>.<\/p>\n