2026 Annual IBICA Conference Registration Please enable JavaScript in your browser to complete this form. - Step 1 of 3Name *FirstLastEmail *Primary Phone Number *Mobile Phone NumberPlease provide a phone number for any contact necessary during the conference.Clubhouse Name *--- Select Choice ---ADAPT ClubhouseAnna's HouseBeacon HouseBeechwood NeuroRehab ClubhouseBICC of Western MassBIN FWBIN PlanoBridgeLine PlaceBrooks ClubhouseDenbigh HouseEmpower House QCAGateway ClubhouseIllinois Valley Brain Injury ClubhouseMidwest Brain Injury ClubhouseMill HouseNew Start Brain Injury Community CenterOpportunity Project ClubhouseSafe Minds Community CenterSeven Hills NeuroCare Brain Injury ClubhouseSide by Side Brain Injury ClubhouseSynapse HouseVinfen Brain Injury Community CenterOther not listedI am not associated with an IBICA Member Clubhouse.Clubhouse Role: *MemberFamily MemberAdministratorStaff MemberBoard MemberOtherRegistration Type: *In Person Individual Conference RegistrationClubhouse Registration for Virtual AccessPlease note: The virtual conference registration fee of $300 is for unlimited simultaneous users. ** No registration fees include travel costs! ** Must submit a form for EACH person who is attending in person.NextI would like to attend: *Full Conference (Tuesday, Sept 15th - Friday, Sept 18th) - $150.00Tuesday, Sept 15th ONLY - $25.00Wednesday, Sept 16th ONLY - $50.00Thursday, Sept 17th ONLY - $50.00Friday, Sept 18th, ONLY - $25.00Do you need any special accommodations to participate in the conference sessions? (copy)YesNoAccommodations Needed:Do you have any dietary restrictions?YesNoDietary Restrictions:NextBilling AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeConference Registration Payment *PayPal CheckoutCredit CardCard NumberExpiration DateSecurity CodeCard Holder NameComments or QuestionsEmailSubmit