Paper Registration Form - WC8
If you have trouble with our online form, feel free to use this paper version for Registration. You may email, mail, or fax it to us.
Registration: Reno, Nevada, June 2010 Name:______________________________________________________________________________
Institutional Affiliation: (university/ private practice/ etc.) ______________________________________
Mailing Address:_______________________________________________________________________ City:________________________________________ State:_________________ Zip:_______________
Daytime Phone:_________________________________ Fax:__________________________________
Email address (required):________________________________________________________________
First Name (as you’d like it to appear on your name badge): ___________________________________
First & Last Name (as you’d like it to appear on your name badge): ______________________________
Affiliation (as you’d like it to appear on your name badge): ____________________________________
City, State, Country (as you’d like it to appear on your name badge): ____________________________
Meal Preference: _____ non-vegetarian _____ vegetarian
Type of Certificate/ CE credits needed (please choose one):
____ no certificate needed
____ general certificate of attendance
____ general certificate of attendance with number of hours attended (must sign in onsite to receive this)
____ CE credits for Psychologists (APA type)
____ California LCSW or MFT CEs
____ NBCC for counselors (pending approval)
____ NASW credits (pending approval)
License Number (if you need it to appear on your certificate): ______________________
For the 2-day Workshops (June 19-20) (these workshops run concurrently, you may choose to attend only one)
Note: Fees include 2 lunches, coffee/tea on site, as well as transportation to/from the conference hotel.
Note: Fees for the MEDITATION RETREAT (June 18-20) include shared dorm sleeping, 2 breakfasts, 2 lunches, and 2 dinners. Please mark the 2-day workshop you wish to attend:
______ Lisa Coyne
_____Professionals/Affiliates: $305 (for above workshops)
_____Students: $170 (for above workshops)
______ JoAnne Dahl, Lindsay Fletcher, & Fredrik Livheim (Meditation Retreat Workshop)
_____Professionals/Affiliates: $365 (for Meditation Retreat Workshop)
_____Students: $200 (for Meditation Retreat Workshop)
__________ Total Cost
You may pay via Visa, MasterCard, American Express, PayPal, or by a check in US Dollars.
I am paying by : ______________________
PayPal: Go to http://www.paypal.com/sendmoney Our account is under the email address: acbs@contextualpsychology.org
Credit Card: If paying by credit card, you may fax your registration to: 1 (225) 302-8688
__Visa __MasterCard __American Express
No.__________________________________ Expiry Date_________ Sec. code _______ Signature:___________________________________
Checks: Please make checks, in US Dollars, payable to ACBS. _______________________________________________
Mail*, fax*, or email this completed form and payment to: ACBS 42398 Haltom Rd. Hammond, LA 70403 USA 1 (225) 302-8688 (fax) acbs@contextualpsychology.org
_______________________________________________
*This form and payment must reach ACBS in Hammond, Louisiana, by June 1, 2010, to take advantage of the Regular Registration Rate. Onsite registration is not available. Note: Registrations are processed in the order that they are received AND paid for. If a workshop is full before your registration reaches us, you will be contacted to make alternative arrangements. If you send a registration without payment, it does not secure your place, only a registration with payment can do that.
Note: Some CEs require post-conference paperwork completion, as well as onsite sign in, for the credits to be awarded.
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Note: A $25 processing fee will be charged for registration refunds up to June 1, 2010. We regret that after June 1, 2010, refunds can not be made. Enrollment may be limited due to the limitation of our venue to accommodate additional sessions and attendees.