2019 ASI Conference Registration Form — Online Payment 2019 ASI Conference registration This is the hub form for our ASI conference registration. Contact InformationEmail* Enter Email Confirm Email If you do not have an email address, please print form and mail or fax to ASI 14 Whitney Farm Road, Mt. Desert, ME USA 05660 Fax: 207-244-7678Preferred Family / Group Name*This is used to identify your party at the registration table.Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home PhoneMobile PhoneRegistration for 2019 ConferenceAttendee Information-please complete for your entire party!*First NameLast NameBirth date (children)M/FT-Shirt sizeSpecial needsGuide dog $300 per adult, $250 age 6-17, $150 5 years or younger. Registration fee does not cover hotel room charges or ground transportation. NOTE: Click the (+) symbol to add more attendees.The above prices are discounted 10% through January 31, 2019 when using this online form to pay for your conference registration.Adult registration(s)* Price: $270.00 Quantity: Reflects 10% early bird discount for online payment through January 31, 2019 add Minor (age 6-17) registration(s) Minor (age 6-17) registration(s)* Price: $225.00 Quantity: Reflects 10% early bird discount for online payment through January 31, 2019 add Child (5 or under) registration(s) Child 5 and under registration(s)* Price: $135.00 Quantity: Reflects 10% early bird discount for online payment through January 31, 2019Angel donation Can you help another family attend? If so, please consider an Angel donation to help get them to Plymouth.Registration PaymentTotal $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name EmailThis field is for validation purposes and should be left unchanged. Last modified: 10th October, 2018
