Attendee Registration Food Matters to Grey Matter The Gut-Brain Connection: A Holistic Approach to Treatment and Prevention of Cognitive Decline Wednesday, November 6th, 2019 – 8:30am to 4:00pm NY ALCA Attendee Conference Brochure * fields are mandatory. Failure to fill out complete information will result in an error.Contact Information Contact person completing this registration:Attendee First Name: * RequiredAttendee Last Name: * RequiredAttendee Title: * RequiredOrganization/Company Name: * RequiredOrganization/ Company Mailing Address: * Required Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Company website: * RequiredAttendee Office Phone: * RequiredAttendee Cell Phone: * RequiredAttendee Fax:Attendee Direct E-mail: * Required My organization is a sponsor or exhibitor at this year’s event: * RequiredYesNoI wish to be listed as an exhibitor: (must be approved by Organization’s contact) * RequiredYesNoI wish to be listed as an attendee: * RequiredYesNoI will be requiring continuing education units: * RequiredYesNoI understand that NACCM and NYSED and other continuing education units are specifically for social work and I am responsible to reach out to my own governing body to see if these credits are applicable" * RequiredYesI understand that to receive continuing education units, I MUST * Required1.) Sign in with registration in person, prior to 9:30am 2.) Sign out with registration in person, after 4:00pm AND 3.) Submit a completed evaluation form for all speakers Yes(Failure to input a license number correctly may result in processing delays of continuing education units).I have a social worker’s license: * RequiredYesNoMy social worker license number is: * RequiredI have another license number: * RequiredYesNoMy OTHER license number is: * RequiredI am a member of the NY ALCA: * RequiredYesNoI am a member of another ALCA Chapter: * RequiredYesNoPlease specify other ALCA Chapter name:First time NY ALCA event attendee? * RequiredYesNoIndicate if Kosher food is needed: * RequiredYesNoHow did you hear about this conference:I will be attending the cocktail party: * RequiredYesNoIndicate if Kosher food is needed: * RequiredYesNoConference Brochure NY ALCA Attendee Conference BrochureI have read the Conference Brochure (see directly above): * RequiredYesPricing Levels: * RequiredSelect oneStandard ALCA member/exhibitor conference + cocktail party $295.00Standard ALCA member/exhibitor conference only $250.00Cocktail reception only (Pre-paid ticket required) $45.00Standard Non-ALCA member conference + cocktail party $320.00Standard Non-ALCA member conference only $275.00Total $0.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name * fields are mandatory. Failure to fill out complete information will result in an error.