Tools for the Journey Conference at Club 21

Please select from the drop down menu:

Organization or School of Employment (if not a parent):

First Name

Last Name

E-mail

Phone

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Child Name

Age of Child

Grade

School

School District

Are you a part of Club 21's Educational Partnership program:

Club 21 Member?

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I will require Spanish Translation

Conference Registration

Member 1 day: $350
Member both days: $400
Non-member 1 day: $450
Non-member both days: $500

If you are attending 1 day, which day will you be attending?

Friday, January 24, 2025
Saturday, January 25, 2025

Would you like to add an additional registrant for Friday, January 24?

The standard fees only include attendance for one registrant. Each additional registrant is $25 per day.

Name of Additional Registrant

If you want your Additional Participant to also receive notifications please provide their email:

Would you like to add an additional registrant for Saturday, January 25?

Name of Additional Registrant

If you want your Additional Participant to also receive notifications please provide their email:

Will you be asking your Regional Center or using self-determination for this conference?

If yes, please check box:

By checking this box, I understand that if my Regional Center does not approve my conference registration I will be responsible for paying Club 21 in full for the registration fee.

Regional Center:

Regional Center Coordinator Name:

Regional Center Coordinator Email

If you are using Self Determination funds, please fill out the information below:

Independent Facilitator's name

Independent Facilitator's email

Financial Management Services name (FMS)

FMS email

Service Code:

UCI #:

Additional Comments or Questions:

Payment Option

Pay now: I will be paying for the conference
Pay later: I will be using Regional Center or Self Determination Funds

Credit Card Information

Cardholder Name

Credit Card #

Expiration Date

Security Code

Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged

Tools for the Journey Registration

Tools for the Journey Registration

Tools for the Journey January 24-25, 2025

Credit Card Information

Tools for the Journey Registration

Tools for the Journey Registration

Tools for the Journey January 24-25, 2025

Credit Card Information

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