Kansas Association of School Psychologists

2012 Convention Registration Form

A registration form must be filled out on each individual planning to attend.

First Name *
Last Name *
Home Mailing Address
Home Address Line 2 (if needed)
City *
State	Zip *
Telephone	- -
Email *
Employer
Employer Mailing Address
Employer Address Line 2 (if needed)
Employer City
Employer State	Zip
Employer Telephone	- -
Early registration must be submitted via the website or, if mailed, must be postmarked by 9/10/12

KASP member rates apply to those who currently are, or by 9/10/12 will be, dues-paid members of KASP.

	I am a member of KASP who will be attending both days: Amount Due Early $125.00 : Late $175.00
	I am a KASP member who be attending Thursday only: Amount Due Early $95.00 : Late $125.00.
	I am a KASP member who be attending Friday only: Amount Due Early $95.00 : Late $125.00.
	I am not a member of KASP. I will be attending both days: Amount Due Early $195.00 : Late $225.00
	I am not a KASP member. I will be attending Thursday only: Amount Due Early $95.00 : Late $125.00.
	I am not a KASP member. I will be attending Friday only: Amount Due Early $95.00 : Late $125.00.
	I am a student. (Full time-verified: have an advisor email jpersing@emporia.edu from their official school email): Provisionally-certified interns earning a full professional salary are not eligible for the conference rate as a student. Amount Due Early $45.00 : Late $65.00.


	Refund policy: If you are unable to attend, a full refund will be made if notified by October 2, 2012. Notification can be made by emailing KASP executive manager Keely Persinger at keelypersinger@yahoo.com.
Warning: If registering by midnight on 9/10, you ARE eligible for early pricing, but the receipt generated when you click the submit button may incorrectly show that late pricing applies. Please disregard!
If you have problems with this form, please wait a few minutes and try again. If it works properly, it will give you a confirmation receipt. If still giving you trouble, please inform the webmaster at jpersing@emporia.edu of your troubles so I can fix it. Then check back in a few days, or just download the traditional paper form available at the link on the left, and mail it in.