32nd Annual Conference Registration Form          
   September 14-16, 2017 San Diego, California              
                 
                 
Name(s) of Attendee(s):            
Street Address              
City, State, Zip              
Phone                
Email Address              
  Please list all names of attendees          
                 
  Is this your first time to attend conference?  Yes    or     No      
Number of Attendees:  Conference          
  Members $90 each            
  Non-Member $100 each          
                 
  Total to submit to QLA __________________________        
                 
Number who will attend the following:          
Thursday Reception              
Friday Breakfast              
Friday Luncheon              
Saturday Breakfast              
Saturday Luncheon              
Saturday Dinner              
                 
Mail Checks and Registration Forms to:          
Quality Life Association, Inc.            
4327 S. Hwy 27, #417            
Clermont, FL 34711              
                 
Credit Card Information:            
Type of Card (Visa, Mastercard or AMEX) ______________        
Card Number     _______________________________________    
3 Digit Sec Code     ________________        
Expiration date     ________________        
Billing address if different from above          
        _______________________________________    
                 
        _______________________________________    
                 
        _______________________________________    
                 
Amount to be charged:   _________________________        
(Registrations for Conference only after August 15th subject to Late fee $10)        
                 
I agree to have my name, address, phone and email shared with other registrants at        
this conference_______________________________________     or        
I prefer to not have my information shared__________________________________        
                 
Consent to Use Photographic Images          
I understand that I may be the subject of photographs or videos that will be taken during        
this meeting, and that they will be included into QLA's stock files.  I agree that photographs         
or videos shall be the sole property of QLA, with full right of lawful disposition in any manner.        
By registering for this conference, I hereby grant QLA permission to photograph or video        
record me during activities and to use the photographs or videos in QLA audio-visual and printed      
materials without compensation or approval rights.          
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