Rates per person:
$150 Before 03/10/2012
$165 After 03/10/2012
Lunch and refreshments included in registration fee.

10% Discount for groups of 3 or more, must call 760-773-4342 for this discount. 

For a printable version click here.

Please register early. Space is limited.

Registrant Information	(Person Attending)
	If you are registering someone other than yourself, please enter that persons information under the Registrant Information fields.
Company Name
Professional Title/Credential:	PHD LCSW LMFT LMHC LPC Addiction Counselor Other
Certification/License#	For Continuing Education credits, a Certification/License # is required. If you do not have a Certification/License #, please enter "None".
First Name:
Last Name:
Address:
City:
State:	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Home Phone:
Work Phone:
Fax:
E-mail:
Billing Information	Same As Registrant
First Name:
Last Name:
Address:
City:
State:	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachussetts Michigan Minnesota Mississippi Missouri Montana Nebraska New Hampshire New Jersey New Mexico Nevada New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
Zip:
Card Type	Select Card Type Visa MasterCard Discover American Express
Card Number
Expiration Date	01 02 03 04 05 06 07 08 09 10 11 12 2012 2013 2014 2015 2016 2017 2018 2019 2020
Card Verification Number
Cancellations and Refunds	All cancellations are subject to a $40.00 cancellation fee. Cancellations after March 10, 2012 will forfeit the entire registration fee.
Captcha:	Type the two words:
	Click the Submit button once, otherwise it may result in multiple transactions.