2023 Annual Conference Registration Form

2023 ANNUAL CONFERENCE REGISTRATION FORM

JULY 24 - 26, 2023
Name (As It Appears on Name Tag)*

First NameLast Name
Pronouns (e.g., she/her, he/him, they/them)
Organization (As It Appears on Name Tag)
Position / Title
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*

Confirmation Emailexample@example.com
Primary Phone Number*
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Please be certain the above contact information is correct. If meeting planners have questions in advance or during this event, the best way to reach me is:*

EmailText MessagePrimary Phone NumberCell Phone Number
CONFERENCE ACCESSIBILTY

GGS endeavors to provide inclusive and accessible programming for all. Please let us know what you will need to successfully participate in our Annual Conference. Certain accommodations require more time to fulfill, so please give us ample time to do so.
Do you have dietary restrictions?*

YesNo
If yes, choose all that apply. If you choose Other, please list.

VegetarianEggsVeganBeefKosherFishSugar-freeShellfishGluten/Wheat/OatsPeanutsDairy/CaseinTree NutsSoybeansSeeds (Sesame, Poppy, Sunflower)CoconutTomatoesOther
Do you require any type of accommodations? For non-dietary accommodations, please email Sarah at administrator@georgiagerontologysociety.org in addition to filling out the form. Put "conference accommodations" in the subject line.*

YesNo - I do not need any modifications to participate.
Communication formats/aids:

Closed CaptioningAssistive listening device (e.g., pocket talker)Other
Materials provided in:

Large printBrailleElectronic files (formats may include PDF or Word)Other
I need a "handicap-accessible" parking space:

YesNo
List other accommodations needed:
I use the following assistive mobility devices:
I will be accompanied by a service animal:

YesNo
Type of service animal:
I will be accompanied by a personal assistant:

YesNo
GGS MEMBERSHIP: Are you a GGS member? You can become a member at www.georgiagerontologysociety.org. Your membership must be current during the conference to maintain the member discount. If your membership expires between the time of your resignation and the conference, you will be required to pay the difference if you do not renew your membership.*

YesNo
ATTENDEE INFORMATION
Is this your first GGS Conference?*

YesNo
I would like to be assigned a conference mentor to assist me with meeting others in the aging network and getting the most out of your conference experience.

YesNo
I am willing to serve as a GGS Conference Mentor to a first-time attendee.

YesNo
Which of these categories do you identify yourself with?

Government/Public/Community Agency or OrganizationNon-ProfitBusiness (For-Profit)AcademiaStudentRetiredOther
Which of the following best describes the over-arching service you work in?

Health Care Delivery - Home or Residential SettingHealth Care Delivery - Hospital or Office / Clinic SettingEducation / Training / Work Force DevelopmentHome & Community-Based ServicesHousing / Residential SettingLegal / Financial ServicesAdvocacy / Public PolicyMental HealthNot Applicable (Retired or Not Working)Other
In what profession do you consider yourself?

Advanced Practice Nurse / Physician's AssistantActivity specialist / Recreation / WellnessAllied Health ProfessionalBusiness (For Profit)CaregiverCase Manager / Care ManagerCommunity Outreach / MarketingFinancial ServicesHealth / Human Services Program ManagerLegal Services / LawyerLTC / Residential ServicesMental Health Counselor / PsychologistNurse (RN / LPN / Nurse Practitioner)Patient Advocacy / Public PolicyPhysician / GeriatricianProfessor / Educator / GerontologistSocial Worker / LPC / LMFTOther
Please identify the coverage area in which you work or where you live if you are not currently working. You man choose more that one option if you cover more than one area. If you are unsure what region you cover, please see the breakdown included in the PDF form.

Central Savannah RiverCoastal GeorgiaGeorgia MountainsHeart of GeorgiaMetro AtlantaMiddle GeorgiaNortheast GeorgiaNorthwest GeorgiaRiver ValleySouthern GeorgiaSouthwest GeorgiaThree RiversAll RegionsOut of StateOther
REFUND POLICY

If you need to cancel your registration, the cancellation must be in writing via mail or email by midnight June 30, 2023. You will be charged a $35.00 cancellation fee. No refunds will be given after June 30, 2023. You may transfer a registration to another individual until midnight on July 18, 2023. Please contact Sarah at administrator@georgiagerontologysociety.org if you transfer a registration.
My Products
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FULL CONFERENCE ~ July 24-26 ~ EARLY BIRD RATES ~ Before June 4, 11:59 PM

FULL CONFERENCE ~ July 24-26 ~ REGULAR RATES ~ Begin June 5, 12:00 AM

TUESDAY, July 25 ONLY ~ EARLY BIRD RATES ~ Before June 4, 11:59 PM

TUESDAY, July 25 ONLY ~ REGULAR RATES ~ Begin June 5, 12:00 AM

CONFERENCE EXTRAS
prevnext( X )
FULL CONFERENCE ~ July 24-26 ~ EARLY BIRD RATES ~ Before June 4, 11:59 PM

GGS Member
$320.00 Quantity



Non-GGS Member
$370.00 Quantity



Student / Retiree (Not Working Full Time)
$210.00 Quantity



Family Caregiver
$210.00 Quantity



Presenter Rate (Student / Retiree)
$160.00 Quantity



Presenter Rate (Professional)
$270.00 Quantity



FULL CONFERENCE ~ July 24-26 ~ REGULAR RATES ~ Begin June 5, 12:00 AM

GGS Member
$360.00 Quantity



Non-GGS Member
$420.00 Quantity



Student / Retiree (Not Working Full Time)
$250.00 Quantity



Family Caregiver
$250.00 Quantity



Presenter Rate (Student / Retiree)
$200.00 Quantity



Presenter Rate (Professional)
$310.00 Quantity



TUESDAY, July 25 ONLY ~ EARLY BIRD RATES ~ Before June 4, 11:59 PM

GGS Member
$195.00 Quantity



Non-GGS Member
$220.00 Quantity



Student / Retiree (Not Working Full Time)
$110.00 Quantity



Family Caregiver
$110.00 Quantity



TUESDAY, July 25 ONLY ~ REGULAR RATES ~ Begin June 5, 12:00 AM

GGS Member
$245.00 Quantity



Non-GGS Member
$270.00 Quantity



Student / Retiree (Not Working Full Time)
$160.00 Quantity



Family Caregiver
$160.00 Quantity



CONFERENCE EXTRAS

GUEST TICKETS ONLY~ Awards and Annual Meeting Luncheon ~ Early Bird Rate ~ Ends June 4, 11:59 PM If you are registered for the conference for that day, you do not need a ticket. These are luncheon tickets for guests.
$110.00



GUEST TICKETS ONLY~Awards and Annual Meeting Luncheon ~ Regular Rates ~ Begin June 5, 12:00 AM If you are registered for the conference for that day, you do not need a ticket. These are luncheon tickets for guests.
$120.00



CERTIFICATE OF ATTENDANCE ~ Early Bird Rates ~ Before June 4, 11:59 PMThe certificate lists the hours attended, event dates, and location. It is not a substitute for the CEU certificate.
$15.00 Quantity



CERTIFICATE OF ATTENDANCE ~ Regular Rates ~ Begin June 5, 12:00 AMThe certificate lists the hours attended, event dates, and location. It is not a substitution for the CEU certificate.
$20.00 Quantity



CEU PROCESSING ~ Early Bird Rates ~ Before June 4, 11:59 PMIf you are requesting CEUs from more than one approving organization, you will need to pay the fee for each. If we are not approved by your organization you can request a refund by July 9, 2023. You must submit the evaluation form to receive CEUs.
$25.00 Quantity



CEU PROCESSING ~Regular Rates ~ Begin June 5, 12:00 AMIf you are requesting CEUs from more than one approving organization, you will need to pay the fee for each. If we are not approved by your organization, you may request a refund by July 9, 2023. You must submit the evaluation form to receive CEUs.
$30.00 Quantity



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2023 ANNUAL CONFERENCE REGISTRATION FORM