2010 MWCT Marketing Reservation Form

2010 Midwest Care & Treatment Education Conference
Beyond Evidence-based & Into Best Practices

Marketing Reservation Form

Organization Name

Primary Contact's First Name

Primary Contact's Last Name

Organization Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Work Phone

(format xxx-xxx-xxxx)

Mobile Phone

(format xxx-xxx-xxxx)

FAX
(format xxx-xxx-xxxx)

E-mail

Confirm E-mail

Please indicate who will represent your organization at the conference:

Representative #1 First Name

Representative #1 Last Name

Representative #1 Email

Representative #2 First Name

Representative #2 Last Name

Representative #2 Email

Brief description of your organization/products/services for program (60-word max.):

Marketing Options

Hold down the CTRL key to select multiple options.

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 reservation form

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

Your reservation fee entitles you to conference sessions, program, certificate, refreshment breaks and the Monday evening social. Lodging and meal reservations should be made directly with Cragun's. 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 February 19, 2010 will be honored.

SPECIAL NEEDS: Please indicate if you have any special needs or requests. Please indicate if you need an electrical outlet for your exhibit or if you wish to be placed adjacent to another exhibitor.

THANK YOU!

Brick Wall Image Midwest C&T Conference
March 7-9, 2010

Cragun's Conference Center
Brainerd, MN

Key Dates

February

19 Early Registration Discount Ends

March

7 Conference Begins with workshops

9 Conference Ends

12 Post-Conference Discussion Available