ONLINE REGISTRATION FORM
(MasterCard and Visa payments only)

  
 

THE MENDED HEARTS 57TH ANNUAL CONVENTION
June 6 - 10, 2009

 
 
MEMBER INFORMATION
(For accurate meal schedules, each registrant must fill out an online form)
  
                 
     
* Required
 
HOTEL INFORMATION

Please contact the hotel directly regarding your hotel accommodations. The Mended Hearts-negotiated hotel convention sleeping room rate is $110 single/double/triple/quad occupancy + 6.5% tax. To receive the MHI negotiated rate, reservations must be made by May 6, 2009. Be sure to ask for the Mended Hearts Group Rate in the "North Tower." For those who wish to come into town early or stay later, the group rate will apply June 3 through June 13, 2009 based on availability. For reservations, go to their website: www.doubletreeorlando.com OR call the hotel toll-free at 1-800-222-TREE OR 407-351-1000. All hotel changes must be made directly with the Doubletree Hotel.

NOTE: Room reservations for Board of Directors and ARDs will be made by the National office.
 
 
Last Name
   *    
 
First Name
   *    
 
Nickname (for badge)
      
 
1st Time Attendee
      
 
Attend 1st-Timer Workshop
      
 
I would like to be a buddy
      
           
 
Mailing Address
   *    
         
 
City
   *    
 
State
   *    
 
Zip
   *    
           
 
Chapter #
   *    
 
Chapter City
      
 
Chapter State
      
           
 
Home Phone
   *    
 
Cell Phone
      
 
E-mail
   *    
           
 
EMERGENCY CONTACT INFORMATION
  
                 
 
Last Name
    
First Name
    
 
Home Phone
    
Cell Phone
    
                 
 
CONVENTION FEE SCHEDULE
  
 
Please select either Option #1 or Option #2.
  
     
 

OPTION #1 - Package Price
Package includes registration fee, 4 luncheons and 2 dinners
 $290 (After May 1, price includes $25 late fee)

 

  
  OPTION #2 - A la Carte Prices (meals include registration fee)    
  Saturday, June 6      
  $65.00 (Welcome Dinner + Registration Fee)  
OR
  $15.00 (Registration only - no meal)  
 
Sunday, June 7 		 
  $55.00 (Luncheon + Registration Fee)  
OR
   $15.00 (Registration only - no meal)  
 
Monday, June 8 		 
  $55.00 (Luncheon + Registration Fee)  
OR
  $15.00 (Registration only - no meal)  
 
Tuesday, June 9		  
  $55.00 (Luncheon + Registration Fee)  
OR
  $15.00 (Registration only - no meal)  
 
Wednesday, June 10		  
  No meals  
OR
  $15.00 (Registration only - no meals)  
  $55.00 (Luncheon only + Registration Fee)          
  $65.00 (Farewell Dinner only + Registration Fee)      
 
  $105 (Luncheon + Farewell Dinner + Registration Fee)  
     
 

TOTAL:

 
 
(If you selected A la Carte options and your total is more than $335, double check your selections).
  
                 
 
CANCELLATION POLICY
  
                 
 
  • 100% refundable if canceled prior to April 30, 2009
  • 50% refundable if canceled between May 1 and May 15, 2009
  • No refund after May 16, 2009 without National President approval

    All refunds will be made in the manner payment was received.
  
 
COMPLIMENTARY T-SHIRT
 
                 
 

Each Mended Hearts convention attendee will receive a free convention logo T-shirt. Please indicate size below. Sizes are adult male/female:

Small Medium Large X-Large XX-Large XXX_Large

  
                 
 
CREDIT CARD PAYMENT
  
  Mended Hearts is committed to ensuring the security of your information. The Mended Hearts Marketplace uses the Secure Sockets Layer (SSL) security protocol, the most widely accepted Internet encryption standard. This system protects your private information while it is transferred from your computer's server to ours.          
 
 
Name (as it appears on card)
   *          
 
Type of card
            
 
Card Number
   *          
 
Expiration Date
   Month Year      
                 
  Billing Information is the same as Member Information  
                 
 
Last Name
   *          
 
First Name
   *          
 
Address
   *          
               
 
City
   *          
 
State
   *          
 
Zip
   *          
                 
 
UPON RECEIPT OF THIS FORM, THE CARD # PROVIDED WILL BE CHARGED THE FULL AMOUNT.
NO REFUNDS WILL BE MADE AFTER MAY 16, 2009 WITHOUT PRESIDENT APPROVAL.
 
                 
 
SPECIAL REQUESTS / DIETARY REQUESTS
  
                 
 

Please list any special dietary requests:
Please list any medical conditions we need to be aware of:
Additional comments or instructions:

I would like more information on renting a scooter Yes No

 
 
 
 

 
     
     

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