2010 Midwest Care & Treatment Registration Form

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

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:

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. 19, 2010 will be honored.

Registration Options

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

$30 Reading Workshop

$30 Behavior Workshop

N/A I do not plan to attend a pre-conference workshop

Regular Conference (Monday-Tuesday)

$100 Presenter/Professional Member Rate (select below)

$100 each Group Rate (5 or more registrations submitted/paid together). Enter group member names below:

$125 Early Registration Rate (submitted/faxed/postmarked by Feb. 19, 2010)

$145 Regular Registration Rate

N/A Exhibitor/Sponsor (included with Marketing Reservation)

N/A Staff

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!