Registration: Adult Development & Aging (ADA) Program Focus Team (PFT) Retreat

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1:30 p.m., April 18, 2012 - 4:00 p.m., April 19, 2012

To register, please fill out the form below. When finished, click on "Submit" at the end of the form.

Note: Due date is February 1, 2012

FIRST NAME: *

LAST NAME: *

DEPARTMENT/COUNTY/DISTRICT: *

ADDRESS: *

CITY, STATE ZIP *

TELEPHONE NUMBER: *

E-MAIL ADDRESS: *

Mark below if wishing to attend the fun activity available to early arrivals. (On your own cost.)

Participate in the pre-conference tour of Coffman Museum

Mark below if you would like to join the pre-conference tour group for lunch?

Lunch with the pre-conference tour group

Registration includes:

* materials
* lodging on April 18, 2012, based upon double occupancy
* dinner, April 18, 2012
* breakfast, April 19, 2012
* lunch, April 19, 2012

Are you a member of the ADA Program Focus Team? *

Yes.

No. If no, there is a $75.00 registration fee. If wishing single occupancy of hotel room, the registration fee is $110. Please make check(s) payable to Kansas State University. MAIL TO: Northwest Area Extension Office, Sara Juenemann, PO Box 786, Colby, KS 67701.

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