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Western Regional Fetal Alcohol Spectrum Disorders Conference
May 19-21, 2013 (Sunday night - Tuesday late afternoon)
See website for more information: http://casat.unr.edu/fasd.html

Payment: Complete this form to register by credit card. In order to register by check or purchase order/check, please mail a check or copy of the purchase order to CASAT with your name, email and phone number. Upon receipt of payment, a coupon code will be sent to you to register online, or you may register onsite (pending space availability).

CASAT Address:
Attn: FASD Conference
1664 N. Virginia Street
Mail Stop 279/CASAT
Reno, NV 89557

Registration Questions? Email: fasd.conference@casat.org | Phone: 866.617.2816

Contact Information
First Name:
(Please type your first name as you would like it to appear on your name badge and certificate.)
Middle Name / Initial:
Last Name:
(Please type your last name as you would like it to appear on your name badge and certificate. Do NOT include credentials/licensure. Thank you!)
Agency/Organization/School:
Type of Licensure/Certification:
Mailing Address:
City:
State:
Zip Code:
Preferred Phone Number: (include area code)
Participant Email Address:  (will receive confirmation)
Confirm Participant Email:
Send Copy of Confirmation
To Other Email Address:

(in addition to participant confirmation email)

Participant Registration Information
Registration Information:
Registration Package
CEH Conference Rate $125 (includes printed CEH Certificate)
CME Conference Rate $135 (includes printed CME Certificate)
Special Diet Check ALL that are applicable.

Vegetarian
Vegan
Gluten-free
Dairy-free
Nut Allergy
Special Accomodations: Fill in 'Other' field for needs such as sign language, hearing impaired devices, etc.

ADA - Wheelchair Accessible

 Other:

Cancellation Policy
If you are unable to attend the Conference, please send a written cancellation notice to CASAT (contact information below) that must be received no later than May 01, 2013 by 5pm for a full refund. If your cancellation notice is received after the deadline, a refund will not be possible. Thank you.

CASAT E-mail: fasd.conference@casat.org Fax: Attn: CAADE Conference 775.784.1840
  Please check that you have read and understand the cancellation policy.

Coupon Code (Optional)
Coupon Code (Optional):