Living Well With Hearing Loss Online Registration Form
Online registration form for HLA OR Workshop to be held November 2, 2019. After this form is completed, you will receive an email. Please visit and use the PayPal DONATE button to pay your registration fees.

Email address is used ONLY to confirm registration

Email address *
Full Name *
Your answer
Full Address *
Your answer
Phone number *
Your answer
What is the BEST way to reach you *
Do you need accomodation? If so, please describe.
Your answer
Select Your Registration Fee (includes boxed lunch if registered before October 21st) *
Do you wish a soda beverage (add $1.50 ea)
Are you a Member of the Hearing Loss Association of America? (if YES deduct $10 per member attending from your remittance)
Full Name of Person 2 - if registered as a couple
Your answer
Lunch Choice
Lunch Choice of Person 2 (if registered as a couple)
Are you interested in being a volunteer at this Seminar? *
A copy of your responses will be emailed to the address you provided.
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