BICA Author Study Registration Form

2010 Minnesota Author Study Series

Registration - Mary Casanova, September 24th

Please submit one online registration per participant.

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 workshop, Author Study Templates, attendance certificate, a.m. treats and coffee. REFUND POLICY: Due to the limited size of this workshop, we are unable to accept cancellations. If you are unable to attend, you may send a substitute in your place.

Payment Options

USA Funds only please

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

Total Fee: $135

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!