Recreation Therapists of Indiana, Inc.
Pre-Registration Form
IU Health, Bloomington, IN
November 17 & 18, 2011
Register by October 20th and SAVE MONEY on Conference Registration
Contact Information
Last Name:
First Name:
MI:
Mailing Address: check one
 Home (Home is preferred)
 Office
Address Line 1:
Address Line 2:
City:
State:
Zip:
Phone:
Email:
Membership Information (check the appropriate box)
 Current RTI Member  Renewing Today  Joining Today  Non-Member *if you are a non-member, you
will be automatically converted to a member with your paid registration at the non-member rate unless you indicate in writing that you
do not want to be a member.
The registration price for the conference does not include your membership renewal.
If you join or renew today, you can attend for the member rate.
The student membership is a one-time fee while you are a student
Conference Registration Fees
Full Package: includes registration, one meal Thursday, social, one meal on Friday
RTI Member Fees
Postmarked
Non-Member Fees
Postmarked
After 10-20-2011
After 10-20-2011
Professional
$85.00
$100.00
Professional
$120.00
$135.00
Daily Package: For those individuals that can attend only one day of the two day conference
RTI Member Fees (per day)
Postmarked
Non-Member Fees (per day)
Postmarked
After 10-20-2011
After 10-20-2011
Professional
$60.00
$75.00
Professional
$80.00
$105.00
Please indicate which day you will be attending:  11-17-2011
 11-18-2011
Student Rate: This is for current students only. Please bring your student ID with you to the conference.
RTI Member Fees
Postmarked
Non-Member Fees
Postmarked
After 10-20-2011
After 10-20-2011
Student
$50.00
$65.00
Student
$70.00
$85.00
CEU’s: Please remember to include Continuing Education fee if you need CEU’s.  CEU’s $10.00
TOTAL ENCLOSED:
(Registration,
Membership, CEU’s)
Please make checks or money orders payable to:
Conference
$
Recreation Therapists of Indiana, Inc.
Membership (Please turn $
Please mail completed pre-registration form, membership
over and fill in your
application, and payment to:
RTI, Inc., P.O. Box 22095
membership info)
Indianapolis, IN 46222-0095
CEU fee $
Total Payment $
Special Accommodations
If you have any special needs or requests (environmental, dietary), please contact the conference coordinator,
Marieke Van Puymbroeck at mvp@indiana.edu
Contact RTI for More Information
Please direct any questions to Marieke Van Puymbroeck at mvp@indiana.edu
Hotel Information
Courtyard by Marriott, Bloomington
Courtyard by Marriott
Rate: $99.00+ tax single & double *this rate only good for the first 20 rooms!
www.marriott.com/bmgcy
Don’t wait to reserve your room!**
812-335-8000
Please state you are with Recreation Therapists of Indiana