2012 START Workshop Registration Form

BICA Workshops

Registration - March 2012

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 the 2-day workshop instruction, ART Book or Bookstore Voucher ($36 value), handout, attendance certificate, online discussion board access and beverage/snack breaks daily. Meals and lodging are not included. REFUND POLICY: All refunds will be subject to a 25% handling charge. If you are unable to attend, submit notice in writing. NO refund requests received after February 6, 2012 will be honored.

Registration Options

March 5-6, 2012 - Cragun's Conference Center (Brainerd, MN)
Midwest Care & Treatment Conference - NEW FORMAT
	$195	START Workshop
	$170 each	START Group Rate (3 or more registering together) Please type your group member names:
	$195	Prevention Workshop
	$170 each	Prevention Group Rate (3 or more registering together) Please type your group member names:
March 8-9, 2012 - BICA Goldstein Memorial Library (Roseville, MN)
	$195	START Workshop
	$170 each	START Group Rate (3 or more registering together) Please type your group member names:

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.