Minnesota Fall EBD Conference Registration

Please provide the following contact information:

First Name
Last Name
Middle Initial
Please type your full name as you would like it to appear on badge/certificate
Gender	Male Female
Organization
Address Type	Home Work
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone (format xxx-xxx-xxxx)
Home Phone (format xxx-xxx-xxxx)
FAX (format xxx-xxx-xxxx)
E-mail
Confirm E-mail:

REGISTRATION OPTIONS

The full conference registration fee includes: continental breakfasts, refreshment breaks, two lunches, evening social, materials, all sessions and attendance certificate.

Full Conference (Thursday - Friday)

Please also select the Thursday Evening option below if you plan to attend the full conference plus the extra School-wide PBIS evening session.

MNCCBD Member Rate (current membership required) - $160

        MNCCBD member number

        visit www.mnccbd.org for membership information

MSPA Member Rate (current membership required) - $160

        MSPA member number

        visit www.mnstate.edu/mspa/ for membership information
Pre-Registration Rate (must be received by 10/22/07) - $175
Regular/On-Site Registration Rate - $185
Exhibitor/Sponsor - 1 complimentary registrations included
Staff/Presenter Only - (Pre-Approval Required)

N/A - Not selected

 

Please contact us for group rates for 5 or more registrations

Thursday Evening - FREE & OPEN TO THE PUBLIC

MN School-wide PBIS General Session 6:15-8 p.m. - $ FREE

N/A - Not selected

REFUND POLICY: All refunds will be subject to a 20% handling charge. If you are unable to attend, submit notice in writing. NO refund requests received after October 22, 2007 will be honored.

PAYMENT OPTIONS:

USA Funds only please. Payable to Behavioral Institute for Children and Adolescents

(Fed ID #41-1703237)

Check (mail with copy of registration form)

Check #
Amount $

Purchase Order (mail or fax with copy of registration form)

Purchase Order #
Amount $

Credit/Debit Card - After you submit your registration using the SUBMIT button below, you will receive a confirmation page with an opportunity to enter your credit/debit card information and activate your registration.

Amount $

SPECIAL NEEDS: Please indicate if you have any special needs or requests.

THANK YOU!