2025 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 CenterI am not associated with an IBICA Member Clubhouse.Clubhouse Role: *MemberFamily MemberAdministratorStaff MemberBoard MemberRegistration Type: *In Person Individual Conference RegistrationClubhouse Registration for Virtual Access*Please note: The virtual conference registration fee of $300 is for unlimited simultaneous users. If a Clubhouse sends someone to the conference in person, all associated costs (registration, hotel, and travel) will be deducted from the $300 virtual registration fee. If the expense of sending someone is equal to or greater than $300, the unlimited virtual access will be free. In that case, no additional registration for virtual access is required.NextI would like to attend: *Full Conference (Thursday, July 17th -Friday, July 18th) - $100.00Thursday, July 17th Only - $50.00Friday, July 18th, Only - $25.00I would like to attend: *Full Conference (Thursday, July 17 -Friday, July 18) - $150.00Thursday, July 17th Only - $75.00Friday, July 18th, Only - $50.00Do 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 QuestionsMessageSubmit