Spring Conference O.D. Registration - Kentucky Optometric Association

Your payment should accompany this form in order to receive the early bird discount. All educational meetings as well as the social functions are included in your registration. No ticket orders will be taken over the phone. Requests for additional tickets must be in writing and payment must accompany this order.

PDF Registration
Name:*
First Last Suffix
Badge Name:
(If different than above)
Badge Name
KY License Number:
OE Tracker #
Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell:*
Email:*
Date of Registration:*
MM slash DD slash YYYY
KOA or AOA Member?*
- Yes
- No
- Student Registration
In case of an Emergency Contact:
Name:
First Last
Phone:

Credit Card
Card Details
Cardholder Name
NOTE
There will be a $50 processing fee for cancellations requested on or after 4/2/2021. Cancellations must be made in writing and mailed or faxed to the KOA office.
Total
$0.00
Phone
This field is for validation purposes and should be left unchanged.

Full Conference Registration: