2012 Indiana ED Conference Registration Form

30th Annual Indiana Annual Conference on Emotional Disabilities
From Pearls of Wisdom to Gems for the Future

Registration

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

First Name
Last Name
Organization
Please enter the year you started your professional career
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 March 30, 2012 will be honored.

Registration Options

Thursday-Friday (1 1/2 day conference)

$145 30th Anniversary Special - We invite professionals who have been serving youth for 30 or more years to enjoy a special discount (retired professionals eligible).
Please enter the year you started your professional career:

$145 Group Rate (5 or more registering together)
Please type your group member names:

$160 Presenter Rate (submit a proposal)
$175 Pre-Registration Rate (by March 30, 2012)

$185 Regular Registration Rate (after March 30, 2012)

N/A Exhibitor/Sponsor (2 complimentary registrations included)

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. PLEASE NOTE: YOU WILL NEED TO LINK TO PAYPAL AND COMPLETE YOUR PAYMENT TO ACTIVATE YOUR REGISTRATION.

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

THANK YOU!