TSA 2012 NATIONAL CONFERENCE
REGISTRATION FORM
April 19-22, 2012
Hyatt Regency Crystal City - Arlington, VA

REGISTER ONLINE FROM FEBRUARY 2 - APRIL 9, 2012

Join TSA today for Conference Savings!  TSA members pay lower rates on Newly Diagnosed Seminar
and General Session (TSA individual/professional/family membership qualifies)
Easy to join - as an Individual or Family - see below

THIS FORM IS FOR ONLINE REGISTRATION AND PAYMENT BY CREDIT CARD ONLY
If you do not wish to pay online, click here to print a fill-in form that you may mail or fax to us with your payment (instructions on form)

JOIN TSA NOW AND PAY MEMBER RATES
   $45-Individual        $60-Full Family         $60-Allied Professional        $100-Physician      $5,000-Lifetime

REGISTRATION CATEGORIES - CLICK TO SELECT   multiple choices per registrant are possible; to clear choices click "Reset Form" button at bottom
	A or B or C or D				E or F
REGISTRANT INFORMATION	A	B	C	D	E	F
1st Adult (PRIMARY CONTACT): First Name REQUIRED FOR THIS REGISTRANT Last Name REQUIRED FOR THIS REGISTRANT Address City  State  Zip Phone    Cell Phone E-Mail Vegetarian Meals? Check here:
2nd Adult: First Name  REQUIRED FOR THIS REGISTRANT Last Name  REQUIRED FOR THIS REGISTRANT Address  City   State Zip Phone   Cell Phone E-Mail Vegetarian Meals? Check here:
ADDITIONAL REGISTRANTS
First Name REQUIRED FOR THIS REGISTRANT Last Name REQUIRED FOR THIS REGISTRANT Age (only if 17 or under) Vegetarian Meals? Check:
First Name REQUIRED FOR THIS REGISTRANT Last Name REQUIRED FOR THIS REGISTRANT Age (only if 17 or under) Vegetarian Meals? Check:
First Name REQUIRED FOR THIS REGISTRANT Last Name REQUIRED FOR THIS REGISTRANT Age (only if 17 or under) Vegetarian Meals? Check:
	A	B	C	D	E	F

Help support a Scholarship to Conference -   $5   $10    $25    $50    $100    $250     $500

                               Total Amount $


USE THIS FORM TO REGISTER FEBRUARY 2 THROUGH APRIL 9

AFTER APRIL 9, REGISTRANTS WILL BE CONSIDERED "WALK-INS" OF THE CONFERENCE.
THEY MUST REGISTER AT THE HOTEL AND PAY AN ADDITIONAL $25 LATE FEE.


*The Youth Camp is offered to families attending the Conference by the Tourette Syndrome Camp Organization (TSCO). There is a separate
fee charged by TSCO for the program. The Youth Camp fee of $235 includes materials, transportation, Friday lunch, Saturday lunch, and is
to be paid separately to TSCO. Space is limited to 50 children. TSCO may offer limited financial assistance. Please contact TSCO directly.
Visit the TSCO Web site www.tourettecamp.com or contact Scott Loeff of TSCO at scott63@prodigy.net for information
and to register for this program.   

Scholarship opportunities may be available for teens, young adults, and adults to attend the conference.
Please call the Field Services Department at (718) 224-2999 for more information.