REGISTRATION FORM

Special Payment Plan

IFCO Conference - August 7-13, 2005
Monona Terrace Convention Center - Madison, Wisconsin

Note Please:
One delegate, one accompanying person and children per Registration Form. Form can be duplicated.

Registration Form can only be accepted if accompanied with full payment, Check/Cheque/or Credit Card

Please Check Hotel Information Provided by Selecting the Link Above. We Can Make Your Reservation for You!

** Please print the form below and mail or fax the information to us.

D E L E G A T E   D E T A I L S
FAMILY (LAST) NAME:  _________________________________________________
GIVEN (FIRST) NAME:   _________________________________________________
Organization: ________________________________________________________
Address: _____________________________________________________________
        City: _____________________ State: ___________ Zip Code: _____________
        Country: __________________________ Email:_________________________
        Telephone: ________________________ Facsimile: _____________________

Preferred Name for Badge:_______________________________________________
Special Diet:____________________________________________________________
Disability Assistance:_____________________________________________________
Language: __________________________ Do you require assistance? [] Yes [] No

C H I L D C A R E
Please complete this information if you are registering children 5 - 12 years of age.
Enclose payment for each child.

Number of Children ____     Male ___ Age __                 Female __ Age __
Name: _______________________    Name:_______________________
Name: _______________________    Name: _______________________
Special Diet: _________________________________________________

Credit Card Payment
Cardholder’s Name: _____________________________________________________
__VISA __Mastercard Card Number: ________ _____ _______ _______ 
Expiry Date: ___________________

Cardholder’s Signature: __________________________________________________
Date: _________________

Please make check/cheque payable to Partners in Foster Care.
All payments must be in US Dollars

Forward payment with Form to
Cora E. White
IFCO-2005 Conference Secretary
P.O. Box 2534
Madison, WI 53701-2534

Or Fax: 1-608-274-4838

For Further Information:
Cora E. White, Chair 1-608-274-9111
Or  Conference Hot Line and FAX: 1-608-274-4838

ifco2005@fostering.us

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