CAPA Conference Registration

First Name (Required)

Last Name (Required)

Chapter* (Required)

Facility

Type of Facility

Skilled Nursing

Assisted Living

Independent Living

Adult Day

Memory Care

Full Address (including street, bldg. and suite/apt #) (Required)

City (Required)

State / Province / Region (Required)

Postal / Zip Code (Required)

Country (Required)

Phone (Required)

Email (Required)

Diet

Gluten Free

Vegetarian

Other diet specifics (provide details)

How will you pay? (Required)

$225 Member Full Early-Bird Registration by September 15

$245 Member Full Registration after September 15

$140 Member One-Day Early-Bird Registration by September 15

$150 Member One-Day Registration after September 15

$250 Non-Member Early-Bird Registration by September 15

$270 Non-Member Full Registration after September 15

$160 Non-Member One-Day Early-Bird Registration by September 15

$180 Non-Member One-Day Registration after September 15 (Wednesday)

$180 Non-Member One-Day Registration after September 15 (Thursday)

Make checks payable to CAPA and mail to:

Ginger Clark,
4902 Herndon Circle.,
Colorado Springs, CO 80920

If your company or someone else is paying for your registration please list the name below (Required)

If attending just one day please check one

Wednesday

Thursday

PO BOX 62524
Colorado Springs, CO
80962-2524

Membership Questions?
Breanna Isringhausen
719-248-5846
breisringhausen@outlook.com