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OHIO POLIO NETWORK CONFERENCE Saturday, September 29, 2012 Tuscora Park, 161 Tuscora Avenue, N.W. New Philadelphia, OH 44663 - Main (Indoor) Pavilion REGISTRATION FORM (Please Print) Name:____________________________________Date:___________________
Address:__________________________________________________________
City:__________________________State:__________Zip Code:_____________
E-Mail:_____________________________________________________________
Phone:_____________________________________________________________
* REGISTRATION MUST BE POST MARKED BY SEPT 15, 2012 Individual with disability: $25.00 Individual with disability & one attendant/family $40.00 Name of attendant/family member (for name tag): _________________________________________
Lunch menu consists of baked chicken, Swiss steak & gravy, mashed potatoes, California mixed vegetables, tossed salad, dinner rolls, & pie (apple, cherry & peach) with coffee (regular & decaf), tea (hot or cold), lemonade & water.
___Check if accommodation needed for vegetarians/special needs. Please specify: ____________________________________________________ ___________________________________________________________
*Note: Registration includes the conference and lunch (also a one year membership to OPN with the quarterly newsletter for new members)
Please make checks payable to "Ohio Polio Network" and mail by September 15th to: Ruth McCort 1048 Austin Avenue Akron, OH 44306 (330) 724-8302
List of some hotels in the New Philadelphia, OH area: Hampton Inn (330) 339-7000, Holiday Inn Express (330) 339-7331 Best Western Dutch Valley Inn (330) 339-6500, Schoenbrunn Inn (330) 339-4334 |
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