ICAC 2010 Conference Registration Form

International Child & Adolescent Conference XV

"Bridging Practices to Improve Academic and Social Competence

of Children & Youth"

Please submit one registration form per attendee per event. If you prefer to mail or fax a registration form, you may download a registration form (pdf) or a copy of the complete registration brochure (pdf).

Please provide the following contact information:

First Name

Last Name

Organization

Address Type Home Work

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Work Phone

(format xxx-xxx-xxxx)

Home/Mobile Phone

(format xxx-xxx-xxxx)

FAX
(format xxx-xxx-xxxx)

E-mail

Confirm E-mail:

Your registration fee entitles you to conference sessions, program, attendance certificate, 3 continental breakfasts, 2 lunches, 1 dinner & refreshment breaks. REFUND POLICY: All refunds will be subject to a 25% handling charge. If you are unable to attend, submit notice in writing. NO refund requests received after October 1, 2010 will be honored.

Please choose one of the following registration options:

Presenter $245 (by 10/1) or $270 (10/2 or later)

Member of CCBD or NASP
$245 (by 10/1) or $270 (10/2 or later)

Member Number:

Expiration:

Regular
Non-Member $280 (by 10/1) or $305 (10/2 or later)

Group
(5 or more) $200 each (must register by 10/1 for the group rate)
Last names of group members:

Single Day Only Thursday OR Friday $160 (by 10/1) or $185 (10/2 or later)
Saturday $100 (by 10/1) or $125 (10/2 or later)
Select Day:

Full-time Student $150 (by 10/1) or $175 (10/2 or later)
* Required for student rate:

Advisor must confirm full-time student status with fax on university letterhead to 651-483-3879 or email to: info@behavioralinstitute.org.

Parent of Student with special needs Please contact us at 651-484-5510 for discounted rates

Exhibitor/Sponsor complimentary registrations included with marketing reservation (see marketing descriptions for details and quantities)

Staff and Planning Committee pre-approval required

Thursday Workshop Selection - REQUIRED (see featured sessions for descriptions)

Thursday workshops are included with your registration fee. However, you must pre-register. Thursday lunch will be provided to workshop participants only. Please rank your workshop choices 1-3. Requests will be filled in the order they are received.

Please check this box if you do NOT plan to attend a Thursday workshop
First Choice:
Second Choice:
Third Choice:

PAYMENT INFORMATION:

USA Funds only please. Payable to Behavioral Institute for Children and Adolescents or BICA (Fed ID #41-1703237)

Summary:

Total Registration Fee:

Check check number:
mail with copy of registration form

Purchase Order P.O. number:
mail/fax with copy of registration form

Credit/Debit 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.

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

THANK YOU!