STUDENT REGISTRATION FORM
(PLEASE PRINT)
ARKANSAS SOCIETY OF RADIOLOGIC TECHNOLOGISTS
STATE CONVENTION
APRIL 19-21, 2012
HOLIDAY INN, JONESBORO, ARKANSAS
NAME
_____________________________________ArSRT Member Number____________
ADDRESS______________________________________________________________
City, State,
Zip___________________________________________________________
HOME PHONE
_________________________E-MAIL_________________________________
PRE-REGISTRATION DEADLINE: POSTMARKED BY APRIL 2,2012.
THERE WILL BE A $25.00 PROCESSING FEE FOR LATE REGISTRATION AND A $60 PROCESSING FEE FOR ON-SITE REGISTRATION.
WHICH SCHOOL DO YOU ATTEND?_______________________________________________________
I AM PARTICIPATING IN THE:
LARRY DAVIS MEMORIAL QUIZ BOWL _____________
SCIENTIFIC ESSAY COMPETITION _____________
SCIENTIFIC EXHIBIT COMPETITION _____________
MEETING ATTENDANCE: THURSDAY____ FRIDAY____ SATURDAY____
QUIZ BOWL OBSERVATION _____________
PARTICIPATING STUDENT FEE: $35.00
This includes 3-day convention registration,quiz bowl observation and entry fee for any competition. LUNCH SATURDAY IS NOT INCLUDED. LUNCH TICKETS ARE $25.00 AND SEATING IS LIMITED.
STUDENT LUNCH RESERVATIONS
President’s Luncheon, Saturday, April 21, 2012. Cost is $25 per ticket. Number of tickets____.
_____________________________________________________________________________
MAKE CHECKS PAYABLE TO ArSRT & MAIL WITH REGISTRATION FORM TO: ArSRT, PO BOX 241492, LITTLE ROCK, AR 72223
ALL PARTICIPANTS MUST BE MEMBERS OF THE ArSRT BY FEBRUARY 28TH. SEATING IS NOT GUARANTEED FOR REGISTRATION FORMS POSTMARKED AFTER APRIL 2, 2012.
NO REFUNDS. EXTENUATING CIRCUMSTANCES MUST BE WRITTEN AND POSTMARKED TO THE ArSRT BY APRIL 1, 2012.