2010 Indiana ED Conference Registration Form

2010 Indiana Annual Conference on Emotional Disabilities
Instructional & Behavioral Practices for Students with Challenging Behaviors

Registration

Please submit one online registration per participant. You may also download a form to mail or fax.

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 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, continental breakfasts, refreshment breaks, two lunches, one dinner and the Thursday evening social. 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 April 3, 2010 will be honored.

Registration Options

Thursday-Friday (1 1/2 day conference)

$150 Pre-Registration Rate (by April 3, 2010)

$170 Regular Registration Rate (after April 3, 2010)

N/A Exhibitor/Sponsor (included with exhibit/sponsorship)

N/A Staff/Planning Committee (pre-approval required)

Payment Options

USA Funds only please

Payable to Behavioral Institute for Children and Adolescents (FED ID #41-1703237)

Total 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!