Exhibitor Information Form

Please complete this form and the Exhibitor Agreement to reserve exhibit space, as requested below, for the 2013 National Lifespan Respite Conference on the dates October 16-17, 2013 at the Boston Park Plaza Hotel & Towers, 50 Park Plaza at Arlington Street, Boston, MA. Exhibit space will be open for set up purposes only on Tuesday, October 15, 2013 from 12:00 noon to 11:00 pm. You may also set up prior to 8:00 am on Wednesday, October 16, 2013. One-day exhibitor fees are not available.

Section 1: Company/Organization Information First Name: _______________________________ Last Name: _____________________________

Company/Agency Name: __________________________________________________ Street Address: _______________________________________________________________________ _______________________________________________________________________ City: ___________________________ State: ________ Zip: _____________ Email: _____________________________ Website: ___________________________ Tel: (W) ________________________ (M) ____________________ (Fax) ____________________

Section 2: Exhibitor Table Fees For sponsoring organizations: If you would like to be a conference sponsor, please complete separate sponsorship form in lieu of exhibitor form. Organizations providing $2,500+ sponsorship qualify for free exhibitor space and organizations providing a $1000 to $2,499 sponsorship qualify for discounted exhibitor space on both 10/16/13 and 10/17/13 at the Boston Park Plaza Hotel. Qualifying sponsors will be given first preference of location based on sponsorship level and by date of sponsorship funding being received.

All Other Exhibitors:

Exhibit Table Fees (please select one):

For Profit $750.00 Non-profit $275.00

(Non-profits must attach a copy of their Federal Non-Profit Status letter with Federal Identification Number)

Fee includes:

One 6’ Table, clothed and skirted

One Chair

Centralized wastebaskets Additional fees: Telephone, internet, electrical and audio visual needs are handled by the Boston Park Plaza Hotel & Towers and will incur extra fees. Your company/agency is also responsible for shipping costs and materials may not be received more than three days in advance. If you indicate yes to any of these requests, we will provide more detailed information, order forms, fees and instructions for payment. Do you require: 1) an electrical outlet? Yes No 2) an internet connection? Yes No 3) audio visual equipment? Yes No If yes, please specify______________ 4) telephone? Yes No

Section 3: Payment For profit $_________________________

Non-profit $_________________________

Total $__________________________

Please choose form of payment: Check: Make check payable to: Horace Mann Educational Associates (HMEA) Credit Card: VISA MasterCard Discover American Express

Card Number: _________________________________ Security Code: _________________

Expiration Date: ____________________________________________

Name on card: _______________________________________________

Card holder’s signature: _______________________________________________________

Billing Address:

Street: _______________________________ City: ________________________________

State: ______________________ Zip Code: ________________________

All exhibitor fees are payable no later than August 30, 2013!

To ensure your reservation of exhibitor space,

please email completed form (with payment information) to

conference@massrespite.org

or mail form and payment to:

Massachusetts Lifespan Respite Coalition

PO Box 550113

N. Waltham, MA 02455

a completed copy of this Exhibitor Information Form

payment, and

a signed Exhibitor Agreement

by August 30, 2013!

Thank you for your Support!

HMEA is the fiscal agent for the Conference and is a 501(c)(3) organization.

Massachusetts Lifespan Respite Coalition ARCH National Respite Network and 781-693-5156 703- 256-2084 www.massrespite.org www.archrespite.org

Note: If you have questions about the exhibitor opportunities, please contact Liz Fancher at

conference@massrespite.org or call 617.770.7676 x105.