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WESTERN REGIONAL SURVEY CONFERENCE

2022 REGISTRATION

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NAME (First/Last) NICKNAME or NAME (as you wish it to appear on your badge)
______________________________________________________________________________________________________________________________________________________
COMPANY
______________________________________________________________________________________________________________________________________________________
ADDRESS
______________________________________________________________________________________________________________________________________________________
CITY STATE ZIP
______________________________________________________________________________________________________________________________________________________
PHONE FAX
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E-MAIL
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MEMBER OF WESTFED STATE ASSN.: (Indicate: ASPLS, APLS, CLSA, PLSC, HLSA, ISPLS, MARLS, NALS, NMPS, UCLS, LSAW, PLSW)
______________________________________________________________________________________________________________________________________________________
SPOUSE/GUEST (if attending – see Spouse/Significant Other Registration below)
MEMBER REGISTRATION OPTIONAL ACTIVITIES
BY MAR 2 AFTER MAR 2 AMOUNT AMOUNT

Conference (Wednesday - Saturday) $525 $575 $________ Extra Wednesday Lunch Ticket ____@ $55 $________
Includes: Wednesday through Saturday workshops and sessions. Extra Thursday Lunch Ticket ____@ $55 $________
Includes Refreshment breaks; Wednesday, Thursday, and Friday luncheons,
IceBreaker Reception and Scholarship Auction Dinner. Extra Friday Lunch Ticket ____@ $55 $________
Extra Icebreaker Reception Ticket ____@ $55 $________
Conference One Day $225 $275 $________
Select Day:  Wednesday  Thursday  Friday  Saturday (half day, no discount) Extra Auction/Dinner Ticket ____@ $75 $________
Continuing Education Certificate $25 $________
NON-MEMBER REGISTRATION
BY MAR 2 AFTER MAR 2 AMOUNT
Conference (Wednesday - Saturday) $625 $675 $________ PAYMENT INFORMATION
Includes: Wednesday through Saturday workshops and sessions.
Includes Refreshment breaks; Wednesday, Thursday, and Friday luncheons,
IceBreaker Reception and Scholarship Auction Dinner. Total Enclosed $____________
 Check Enclosed (Checks payable to WRSC Conference)
Conference One Day $325 $375 $________
Select Day:  Wednesday  Thursday  Friday  Saturday (half day, no discount) Charge to:  Visa  MasterCard
OTHER REGISTRATION ____________________________________________________________
Spouse/Significant Other Registration $275 $________ CARDHOLDER NAME
Includes entrance to Exhibit Hall, Wednesday, Thursday,
and Friday Luncheons,Icebreaker Reception, and Scholarship Auction Dinner. ____________________________________________________________
CARD #
Full-time Student Registration $275 $________ ____________________________________________________________
Must attach current student ID.
Includes: Wednesday through Saturday workshops and sessions. EXP. DATE CVV#
Includes Refreshment breaks; Wednesday, Thursday, and Friday luncheons,
IceBreaker Reception and Scholarship Auction Dinner. ____________________________________________________________
BILLING ZIP CODE
____________________________________________________________
AUTHORIZED SIGNATURE

MAIL TO: FAX TO: (707) 578-4406
PHOTO/VIDEO DISCLAIMER: By registering for and attending this WRSC Conference Office
conference, you agree that your image may be taken during the conference 526 South E Street QUESTIONS?
and used at any time, without further notification, for printed materials,
websites, social media, and other marketing purposes. Santa Rosa, CA 95404 (888) 994-3510
conference@plseducation.org
PHOTOGRAPHY, RECORDING, LIVE STREAMING, & VIDEO TAPING:
Attendees/Participants may not record or broadcast audio or video of
sessions, workshops, seminars, etc. CANCELLATIONS: - Cancel by March 2, 2022 to receive a refund,
less a $50 cancellation fee. After March 2, 2022 no refund will be
EXHIBITOR DISCLAIMER: By registering for this conference, you agree available but substitutions can be made. Cancellations must be
that your contact information may be provided to exhibitors for a one-time made in writing by emailing conference@PLSeducation.org
use in providing you information regarding their products/services.

Register Online at: www.PLSeducation.org