Registration Form

Insure the Uninsured Project's 10th Annual Conference

Sacramento Convention Center

First Name

Last Name

Title

Organization

Address 1

Address 2

City

State

Zip Code

Phone

Fax

Email Address

If you are registering a colleague, and future communication should be directed to you, please enter your name and email address here.

Calendar of Activities

ITUP's 10th Annual Conference

Tues., February 7, 2006

I TUP Networking & Awards Dinner

6:00 p.m. - 9:00 p.m.

Wed., February 8, 2006

ITUP Conference

8:00 a.m. - 4:00 p.m.

Please indicate whether you are signing up for the dinner and/or conference. If you are also registering more than one person from your organization, please enter the number of people attending the dinner and/or conference along with their name(s) and email address(es).

ITUP Networking & Awards Dinner

I will be attending the dinner

Yes

No

Indicate # of people that will be attending the Dinner

If you are registering more than one person, please list registrant(s) name and organization.

Select One

Speaker (no charge)

Board Member (no charge)

Regional/ Issue Workgroup Member ($35.00)

Friend of ITUP ($75.00)

Registering >1 person who fall in different categories

ITUP Annual Conference

Indicate # of People Attending the Conference From Your Organization.

If you are registering more than one person, please list registrant names and organization

Select One

Conference Participant ($100.00)

Regional Workgroup Member ($70.00)

Student ($35.00)

Speaker (no charge)

Honoree (no charge)

Board Member (no charge)

Registering >1 person who fall in different categories

Payment Options

Please enter the total dollar amount based on the number of people attending the dinner and/or conference. For example, if your total amount is $175.00 enter ONLY 175.

Select Form of Payment

I will pay by credit card through PayPal in the amount entered above (return to the conference page after completing this registration form and click on the pay online button).

I will mail a check payable to Insure the Uninsured Project in the amount entered above.

To pay by credit card, please return to conference page after completing this registration form, and click on the PayPal button.

Please mail checks to: Insure the Uninsured Project, 2444 Wilshire Blvd., Suite 415, Santa Monica, CA 90403

Conference & Dinner Sponsorship Opportunities

Please indicate if your organization would be interested in learning about conference sponsorship opportunities.

Yes

Hotel Accomodations

If you are interested hotel accomodations, we have secured a limited amount of rooms at the Hyatt Regency Sacramento at a ITUP special rate of $159. Please call the hotel directly at (916) 443-1234.

This hotel is located across the street from the Sacramento Convention Center at 1209 L Street, Sacramento, California, USA

We look forward to seeing you at the conference!


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