Convention 2004 Registration Form

Send Form: with credit card information, or enclosed check payable to IPA, to: IPA, 18 Cedar Hill Rd., Ashland, MA 01721, USA. For more information on payment call 508-881-5678.

Are you a current member? YES ___    NO ___

Circle days attending*:  T/W    W/Th    Th/F    F/S    S/Su    Su/M
*(a day includes 4pm to next day 5pm)

Circle arrival day first meal: Breakfast  Lunch  Dinner

Circle departure day last meal: Breakfast  Lunch  Dinner

Check discounts that apply: Off-Site ___    15% Distance ___    $15 Newcomer ___

Register me (us) for _____ day(s).

My fee is:	___________________________
Second person, fee:	___________________________
Third person, fee:	___________________________
Donation (optional) to IPA Scholarship Fund:	___________________________
Donation (optional) to IPA Development Fund:	___________________________
If renting linens, add $12.00 per person:	___________________________
Total (US funds only):	___________________________
Credit Card Type (Amex not accepted):	_____________________________________________________
Card No.:	_____________________________________________________
Name on Card:	_____________________________________________________
Card Holder's Address	_____________________________________________________ _____________________________________________________
Varification Code:	_______________ (3 digit code in signature area)
Exp. date:	_____________________________________________________
Signature:	_____________________________________________________