Please provide the following contact information:

First Name
Last Name
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Please type your full name as you would like it to appear on badge/certificate
Organization
Address Type	Home Work
Street Address
Address (cont.)
City
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Country
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Home Phone (format xxx-xxx-xxxx)
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REGISTRATION OPTIONS

Pre-Conference Workshop (Sunday 2:00 - 5:00 p.m.)

READING - Using a Three-Tiered Inquiry Approach to Identify and Meet the Needs of Struggling Learners - $30

BEHAVIOR - Programming for Violent Youth - Social Skills Training and Aggression Replacement Techniques (START) - $30

N/A - Not selected

Full Conference (Monday - Tuesday)

CCBD Member Rate (current membership required) - $100

        CCBD member number

        visit www.mnccbd.org for membership information

CEA Member Rate (current membership required) - $100

        CEA member number

        visit www.mnccbd.org for membership information

MSPA Member Rate (current membership required) - $100

        visit www.mnstate.edu/mspa/ for membership information

Group Rate (5 or more registrations sent/paid together) - $100 each

Please submit a separate registration form for each group member (after you have clicked submit below, you can click the back button on your browser to save and edit information)

        Group member names
Pre-Registration Rate (must be postmarked by 2/16/08) - $125
Regular/On-Site Registration Rate - $145
Exhibitor/Sponsor - 1 complimentary registrations included
Staff/Presenter Only - (Pre-Approval Required)

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 Feb. 16, 2008 will be honored.

LODGING:

For conference lodging and meals, please complete a Lodging Reservation Form and return it directly to Cragun's.

Preferred lodging will be held until February 9, 2008. Room rates will be honored after Feb. 9, but room availability is NOT guaranteed.

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!