REGISTRATION FORM

Windows to the Mind: A New Approach to Differential Diagnosis & Treatment of Borderline and
Other Personality Disorders

June 13, 2007

Required fields are red. We will be unable to process your registration form if all required fields are not completed. Thank you.

Name:
Title:
Company:
Street Address :
City:
State, Zip:
, Business Address Home Address
Day Phone:
Business Phone Home Phone
E-mail:
Yes, I would like to join the MHAFC (check category):

Individual: $35 or more Family: $50 or more
Professional: $50-$99   Organization: $125
MHAFC Membership Amount:

REGISTRATION

Conference Registration -
before May 18: $89
after May 18, 2007: $109

 

Box Lunch - deadline for ordering is June 4 $10

  Yes
  No
Vegetarian Box Lunch?
   Yes
  No
DISCOUNTS

MHAFC Member: Deduct $10
Student or retiree: Deduct $20 (Bring copy of your student ID to conference.)
Group (5% discount for 5 or more registering at one time with one charge)
If group registration, how many?
Multiple registrations
Please list the name, address and CEUs requested for each participant

Continuing education credits desired:

This information is required to process your registration. Please select one:
 Social Worker (7 CPEs)
Counselor (7 CPEs)
RN/LPN (7 CEs)
Psychologist (7 MCEs)
Chemical Dependency Counselors (7 RCHs)
 None
Any assistance needed for a disability or sign language interpreter?
Yes - Please explain:
Information required to process your registration.
Name as it appears on the credit card:
Credit Card Number:
Expiration Date:
Credit card billing address if different than above:
Please enter total to be charged to your credit card:
  By submitting this form you are agreeing to the following refund policy: There will be no refunds after June 1, 2005, but you may designate a substitute to attend or request a receipt for a tax-deductible donation. Refunds prior to this date will be assessed a $25 processing fee.