ITMS Conference Registration Form:

Open the Registration Form as a PDF Document

Name:        __________________________________________________________________

Address:    __________________________________________________________________

City:            ___________________________ State, Zip:   _____________________________

Phone:       _____________________        Email: ____________________________________


Registration Fees for the conference and all meals:

          □ ITMS Member - $240.00
          □ ITMS Member - $290.00 Late Registration Fees (between May 15 and June 1)

          □ Non-Member - $290.00
          □ Non-Member - $340.00 Late Registration Fees (between May 15 and June 1)
          □ I prefer a vegetarian entrée at the banquet.
          □ Handicapped/special needs (attach explanation)  (Cancellation Policy)
 

$_______


Accommodation:
          □ $165.00 (single room for three nights - per person)
          □ $120.00 (shared room for three nights - per person)
               
          If sharing, preferred roommate: ________________________
 

 $_______


Additional Lodging Fee:
          □ Wednesday, June 12 - $55.00 (no meals)
          □ Sunday, June 16 - $55.00 (no meals)

 $_______


Daggy Scholarship Fund:
           Would you like to make a donation to the Daggy Youth Scholars Fund?
           Donations to the Daggy Scholarship Fund are tax deductible to the extent allowed by law.
 

 $_______


Total
(made payable to ITMS):  
 

 $_______

Please print and return this form, with check or money order made out to ITMS, to:
Michael W. Higgins
ITMS 2013 Conference
Sacred Heart University
5151 Park Avenue,
Fairfield, CT 06825-1000