Page 45 - 2021_SO_Cover

HEALTH & WELLNESS SUMMIT

COLUMBUS, OHIO OCTOBER 24–26, 2021

Secure your spot now! Space is limited to the first 300 registrants.

REGISTRATION FORM
Payment in full is required prior to the start of the summit and must be made with a credit card, check,
or purchase order. To register online, go to bit.ly/ajahealthsummit. Online registrants who pay by credit card
receive immediate confirmation and payment receipt. Registrants submitting via email, mail, or fax receive email
confirmation within three weeks of receipt. Badges are distributed onsite.
You may cancel up to 30 days prior to the start of the Health and Wellness Summit. No refunds will be given for
cancellations received within 30 days of the event. All cancellations are subject to a $50 service fee.
Your cancellation must be received in writing via fax or email. Substitutions will be acceptable. Please direct
questions to michelef@aja.org.

APPLICANT INFORMATION

Name: Certifications:
Title: Rank:

AJA Member #: Email:

Work Phone: Cell Phone:
AGENCY INFORMATION

Agency Name:

Agency Address:
City: State: ZIP Code:

PERSONAL INFORMATION

Home Address:
City: State: ZIP Code:

Home Phone: Personal Email:
PAYMENT INFORMATION

REGISTRATION FEES: MEMBER $495 NONMEMBER $555 (includes a complimentary 1-year membership)
If paying by credit card or a fully executed purchase order, you may register by completing this form and faxing it to
301–790–2941 or by emailing this completed form to michelef@aja.org.
If paying by check, complete this form and mail with payment to:
American Jail Association • P.O. Box 65048 • Baltimore, MD 21264–5048
(Make checks payable in U.S. funds, drawn on a U.S. bank to American Jail Association.)
Payment Via Credit Card: Charge to:  VISA  MasterCard  American Express  Discover
Account #:_______________________________________________________ Expiration Date: ___________ Security #:________
Cardholder’s Name: _______________________________ Signature of Cardholder:_____________________________________
Billing Address/ZIP Code:______________________________________________________________________________________

Payment Other: PO#: __________________________________________________ Please Invoice: _________________________

AMERICANJails SEPTEMBER | OCTOBER 2021 | 43