Registration Form NCFR Annual Conference 2015

Fillable Printable Registration Form NCFR Annual Conference 2015

Registration Form NCFR Annual Conference 2015

Registration Form

NCFR Annual Conference 2015

November 11-14; Hyatt Regency, Vacouver, British Columbia • www.ncfr.org

Your Information

Name ______________________________________________________________________________________________________

First Middle initial Last

NCFR member number (if applicable) ____________________________________________________________________________

Preferred Address _____________________________________________________________________________________________

City ______________________________________ State/Prov ____________ Country _________ Postal

code

_______________

E-mail _____________________________________________________ Day

phone

______________________________________

FAX _________________________

Organization (or school you attend) _______________________________________________________________________________

Emergency contact (name, phone number) _________________________________________________________________________

Is this your rst NCFR conference? q yes q no

I am q a student q a new professional who graduated in the last ve years

Registration and Fees

Select either Full Conference Registration or Single-Day Registration; also register here for CEUs, Pre-Con, and special events

Part 1: Conference Registration

Full Conference Registration June 16-Oct 12 Oct 13-Nov 14

q NCFR Member $350 $415

q NCFR Student Member* $135 $180

q NCFR Emeritus Member $185 $230

q Non-member professional $485 $550

q Non-member student* $235 $275

Single-Day Registration** June 16-Oct 12 Oct 13-Nov 14

q Professional $195 $245

q Student* $120 $170

Indicate day of attendance: ___Wed ___Thu ___Fri ___Sat

q Guest badge $50. Permits guest of registrant to attend receptions (only). Guest name ________________________________________________

TOTAL Part 1 $____________________________

Part 2: Continuing Education Units / Gifts to NCFR

q Verication of attendance for Continuing Education Units (NBCC, NASW, California BBS), $25

q Verication of attendance for CFLE Recertication, no charge

q Here is my gift to NCFR. Amount $________ q Unrestricted q Restricted; apply specically to ___________________

(tax deductible according to law)

TOTAL Part 2 $____________________________

Part 3: Special Events/Workshops

TCRM Workshop; Tue, Nov 10, 8am-6pm and Wed, Nov 11, 8am-1pm q $50 professional q $35 student

MAXQDA Workshop; Tue, Nov 10, 9am-4:30pm q $300 professional q $225 student

Eradicating Sexual Violence on Campus (Feminism Section), Tue, Nov 10, 8:30am-6pm q $35 includes lunch

Media Training: Writing and Interviewing Skills; Tue, Nov 10, 5-8:30ppm q $125 includes dinner

Afliate Councils/Student Afliates Workshop; Thu, Nov 12, 7:30-11:30am q $15 Professionals q $10 students

TOTAL Part 3 $____________________________

TOTAL CONFERENCE FEES (add parts 1, 2, 3) $__________________________ Go on to page 2

Join NCFR now to qualify for

member registration rates.

Go to www.ncfr.org or call toll free

888-781-9331.

**No discount for members for single-day

* Verication of student status must

be provided if requested.

Payment information

q Check (payable to NCFR) q Visa q MasterCard q American Express q Visa-Japan

Card number ______________________________________________________ Expiration date __________________________

Name on card _____________________________________________________

CVD

code (code on card) ____________

Credit card billing information

Name ______________________________________________________________________________________________________

Address _____________________________________________________________________________________________________

City _____________________________________________ State/Province __________________ Zip/postal code _____________

Signature ___________________________________________________________________________________________________

• All prices are U.S. dollars. Checks/money orders must be drawn on U.S. banks. Overpayments of $10 or less will be considered

contributions to NCFR. Service charge of $30 on all returned checks.

• Payment must accompany registration except for purchase orders which must be pre-arranged with the NCFR nance ofce; in-

voices are due upon receipt; contact morgancole@ncfr.org.

• Refund requests must be in writing and postmarked by October 12, 2015. All refunds are subject to an administrative fee.

• No refunds after October 12, 2015. No refunds for special events/workshops unless the event is cancelled. Refund checks will be

mailed approximately 3 weeks after the conference.

Deadlines/Mailing Address/Contact

• Your registration form must be postmarked by the deadline dates given to qualify for the appropriate registration fee

(June 15 or October 12).

• After October 12, do not mail or fax this form; bring it with you to the conference and register and pay in person.

NCFR Annual Conference Registration

1201 West River Parkway, Suite 200

Minneapolis, MN 55454

Tollfree: 888-781-9331

FAX: 763-781-9348

E-mail: susanbaker@ncfr.org

ADA requirements, roommates, student aides

• Reasonable accommodations for disability can be provided for participation in conference sessions. Personal aide services cannot be

provided by NCFR.

• NCFR staff can assist you in contacting other registrants seeking to share a room.

• NCFR student members may sign up for the Student Aide Program and receive conference registration at a reduced rate. For infor-

mation, visit www.ncfr.org/conference.

If you have questions about these or other conference logistics, contact Judy Schutz, judyschutz@ncfr.org;

toll free 888-781-9331 ext 2893.

Consent to use of photographic/video images

Registration, attendance, or participation at the NCFR Annual Conference constitutes an agreement by the registrant/participant to

NCFR use and distribution (current and future) of his/her image or voice in photographs, video, and audio.

06/17/2015