Registration Form - Our Lady of Holy Cross College

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REGISTRATION Law and Ethics in Counseling Conference 2016 April 3‐7, 2016 Our Lady of Holy Cross College New Orleans, Louisiana A $200 deposit is required upon registration for the conference. The balance of the registration fee is due January 15, 2016. The deposit is refundable upon request until January 15, 2016 and is not refundable after that date. Registration for the conference is limited. Those who register early will be confirmed. After capacity has been reached for residential and commuter registrations, those sending in deposits will not be charged and they will be put on a wait list. If spaces later open up, those on the wait list will be notified and given the opportunity to complete their registration at that point. Costs listed below for resident participants include lodging for four nights, all meals, conference registration, bus transportation for an afternoon in the French Quarter, two receptions, and 16 continuing education hours approved by the National Board for Certified Counselors. Check whether you are registering as a Resident or Commuter Participant: ___ Resident ___ Commuter Resident participants will stay at the Retreat Center during the conference. $695 Option One: single room with sink in room with Jack and Jill bath and toilet shared with one other room $595 Option Two: single room with sink in room with showers and toilets shared by five other rooms located in the hallway (bring a housecoat for trips down the hall if you are assigned this option) If a resident participant, indicate whether your first choice of accommodations is Option One or Option Two: ___ Option One ___ Option Two There are a limited number of Option One rooms that accommodate two persons. If you would like to have a roommate, please indicate his/her name below: ___ Would not prefer a roommate. ___ Would prefer two single beds. Name of preferred roommate: ___ Would prefer one queen bed. Name of preferred roommate: Costs listed below for commuter participants include continuing education hours and lunch on four days (Monday‐Thursday). Commuter participant will stay at a hotel or at home and drive to the conference each day and will have their lunches provided at the conference. $305 Commuter Registration Fee If you are a student enrolled in a degree program in a college or university, you will receive a 25% registration discount. Your registration fee will be $521.25 for Residential Option One; $446.25 for Residential Option Two; or $228.75 for the Commuter Option. If you are a student enrolled in a degree program in a college or university, please provide the following information:  Degree you are working toward: ____________________________________________  Major: _______________________________________  College or university where you are enrolled: _______________________________________  City and state: _________________________________________________ Today’s Date: _________________________________________ Full Name: ___________________________________________ First and Last Name Preferred for Name Tag: _______________________________________________ Mailing Address:______________________________________________________________________ City, State, Zip: _______________________________________________________________________ E‐Mail Address: ____________________________________________________________ Cell Phone:________________________________________________________________ Home Phone: ______________________________________________________________ Office Phone: ______________________________________________________________ If you are not a student and are employed, please provide the following information:  Job title: _______________________________________  Employer:_______________________________________  City and state:____________________________________ List food preferences and allergies below (check all that apply): ___ Vegetarian ___ Vegan ___ Allergic to nuts ___ Must have a gluten‐free diet ___ Allergic to other foods List food allergies: List any medical conditions you wish conference administrators to know about: List any medications currently taking you wish conference administrators to know about: List any disabilities you wish conference administrators to know about. Include any accommodations you are requesting: ___ Check here if you wish to reserve a space for the plantation tour Sunday afternoon, April 3, 2016 departing from the Retreat Center at 12:30 pm. If you indicate you will attend the tour, $80 will be added to your registration fee balance to be paid on January 15, 2016. If you will bring family members or friends with you on this tour who are not registering for the conference, indicate the number of extra spaces you would like to reserve for the tour (in addition to you): ___ Please accept my registration for this conference. Authorization is included below for the $200 deposit to be paid by credit card or I will pay by check for $200 after my registration has been confirmed. I understand the payment schedule for the institute is as follows: $200 deposit due upon submission of this application; balance due on January 15, 2016. NOTE: If you are registering after January 15, 2016, remit the entire amount of your registration fee and include an additional $80 per ticket if you wish to attend the optional plantation tour on April 3, 2017. If you are registering after January 15, 2016, change the $200 each place it is listed below as the amount you are paying or charging. Payment of $200 deposit by ___ credit card ___ check To pay $200 deposit by check after receiving confirmation of your registration, mail check made out to Our Lady of Holy Cross College to the address provided. To pay $200 deposit by credit card, please complete the information below and sign and date: Amount of charge authorized: $200 Type of Credit Card: ___ MasterCard ___ Visa Number on Credit Card: ________________________________________________ Expiration Date: ___________________________________________________ Three Digit Code on Back of Credit Card: __________ Exact Name Listed on Credit Card: ______________________________________________________________ Address Where Credit Card Bill is sent: __________________________________________________________ City, State, Zip: _____________________________________________________________________________ Signature of Credit Card Owner: _______________________________________________________________ Date of Signature: __________________________________________________________________________ If paying by credit card, scan and email your completed application by email attachment to Dr. Ted Remley Conference Director Professor of Counseling Our Lady of Holy Cross College [email protected] If planning to pay by check, your signature is not required. Attach a copy of this completed application and email to Dr. Ted Remley Conference Director Professor of Counseling Our Lady of Holy Cross College [email protected]