REGISTRATION FORM
109th Annual Forum
Ohio Welfare Conference
November 3-5 1999
Cincinnati, Ohio

AGENCY/ORGANIZATION:_______________________________________________________________
TYPE OF AGENCY (PLEASE CHECK ONE): __ DHS__ ODHS __ CSB __  CSEA__ Mental Health
__Municipal Agency  __ Other:____________________________________________________________
MAILING ADDRESS: ___________________________________________________________________
CITY, STATE & ZIP: ____________________________________________________________________
COUNTY: _____________________________________     PHONE NUMBER: ____________________
 

Please circle the appropriate category:	All Days	One Day Only
Pre-Registration Postmarked by 10/11/99	$85	$55
(payment & form must be included)
Registration After 10/11/99	$95	$65
Full Time Student Fee	$25	$15
Name of School: ______________________________ Please attach copy of current student ID
Retired Person Fee	$20	$10
CEU Processing Fee (Must complete & send attached CEU Form)	$15	$15
TOTAL Amount of Enclosed Check or Money Order $ __________		(Do Not Send Cash)

WALK IN REGISTRATIONS ARE WELCOME.

COMPLIMENTARY LUNCHEON REGISTRATION
Complementary full course luncheon must be limited to the first 300 people who register for both days of the conference and who make a commitment to attend! People who wish to attend only on Thursday will be considered on a space available basis.

Indicate below whether or not you wish to attend the luncheon:
__ I will attend the luncheon.     Select one: __ Chicken     __Vegetarian
__ I will not attend the luncheon.

To aid in Conference Planning please indicate the numbers of the workshops you will attend.  You will not be confined to these workshops since all sessions will be open (first come, first seated).  Please indicate preferences below.
 

Wednesday	10:00 a.m. - 11:30 a.m.	Executive Briefing:__ Yes  __No   (limited Seating for Supv/Adm Staff)
Wednesday	1:00 p.m. - 4:30 p.m.	Keynote Address:__ Yes  __No
Thursday	8:30 a.m. - 10:00 a.m.	Workshop Number:  ____________
Thursday	10:15 a.m. - 11:45 a.m.	Workshop Number:  ____________
Thursday	2:45 p.m. - 4:15 p.m.	Workshop Number:  ____________
Friday	8:30 a.m. - 10:00 a.m.	Workshop Number:  ____________
Friday	10:15 a.m. - 11:45 a.m.	Workshop Number:  ____________

CANCELLATIONS:  To receive a refund of your registration fees a written notice must be received no later than October 25, 1999.

BILLINGS:  Only agencies or organizations may be billed for fees.  Enclose a statement on agency letterhead with billing information when you send the individual registration forms.

 MAKE CHECK OR MONEY ORDER PAYABLE TO:  OHIO WELFARE CONFERENCE
                                       MAIL TO:             Brenda Newsom