2015 Conference Registration


Notice: A separate registration is required for each person attending.

*Full Name:
  Mr.   Mrs.  Ms.
*Complete Home mailing address:
Number of Years
in Direct Care:
*Home phone:
Work phone:
Cell phone:
Employer Address:
Employer City:
Employer State:
Employer Zip:
Is this your first time
at conference?
Yes    No
Do you plan to participate in the health screenings? Yes    No
Do you have any special dietary needs? Yes    No
Please list here:

Please contact us at or 515-223-2805 by August 3 for any accommodations and/or alternative formats you may need.

      Please Select Your Occupation (check all that apply):
Certified Nursing Assistant (CNA) Consumer Directed Attendant Care
(CDAC) worker
CNA plus other certification, such as medication aide, rehabilitation aide, etc. Direct Support Professional
Home Care Aide (HCA) Hospice Aide
Home Health Aide (HHA) Companion, non-medical assistant
Universal Worker Other
Patient Care Technician (PCT)  
If other, please specify
*Registration Fees $50 (one day)    $75 (both days)
Days you will be attending
(check all that apply)
Aug. 24     Aug. 25
  If your registration is received after August 17th, 2015, you will be charged an additional $30 special processing fee.