ADHCC Annual Conference
Registration Form (continued)
April 7-8, 2016
Name: ___________________________________________________________________________________________________________
Organization:_____________________________________________________________________________________________________
Payment Method:
Please select: Check
MasterCard Visa Discover Amex
Card number: _______________________________________________________________________________________________________
Exp.:_______________________
Security code: ____________________
Cardholder’s name (exactly as on card):___________________________________________________________________________________
Authorized signature: _________________________________________________________________________________________________
Make check payable to ADHCC
Complete form and return with payment to ADHCC, Attn: Michelle Mahoney.
Mail: 13 British American Blvd., Suite 2, Latham, N.Y. 12110-1431
Phone: 518.867.8385, ext. 154 Fax: 518.867.8386 Email: [email protected]
If you have any questions or a problem that keeps you from attending this conference, please call us. Perhaps we can help.
Contact Tedi DeMartino at 518.867.8385, ext. 117, or email [email protected]
Logistical arrangements for the Adult Day Health Care Council’s Annual Conference have been provided by
the Foundation for Long Term Care (FLTC).