First Name: 

Last Name: 

Organization: 

Mailing Address: 

City:   State:  

Zip Code: 

Daytime Phone: 

Email: 

I consider myself experience as a fire, burn or life safety educator to be: Novice Intermediate Expert

Include my contact information on the participation roster: Yes No

Registration: Full Conference Single Day
(FULL DAY REGISTRATION FEE:  $175 if payment received by May 23 / $200 after May 23)
(SINGLE DAY REGISTRATION FEE:  $90 if payment received by May 23 / $100 after May 23)

If single day registration, I will attend the conference on: Wednesday Thursday Friday

T-Bone Baseball GUEST Tickets - One ticket is included with each conference registration.
# Tickets:   

Method of Payment: 
 Check Credit Card Purchase Order

PAYMENT BY CHECK:  Please print this form after submission and send with check to:  Elena Nuss, 1132 W. 125th, Carbondale, KS 66414

PAYMENT BY CREDIT CARD:  Credit card payments may be made by phone by contacting Elena Nuss at 785-296-3403.

PAYMENT BY PURCHASE ORDER:

PO Number: 

PO Organization: 

PO Organization Address: 

City:   State:  

Zip Code:  

Organization Phone: 

Additional Accommodations Needed: Yes No
If you need any additional accommodations including vegetarian meals, please check Yes.  A member of the conference planning team will contact you.