Registration: World Conference 12 & Pre-Conference Workshops

Minneapolis, Minnesota, USA June 17-22, 2014

Name:______Profession:______

Institutional Affiliation: ______

Mailing Address:______

City:______State:______Zip:______

Daytime Phone:______Fax:______

Email address(required):______

First Name (as you’d like it to appear on your name badge): ______

Last Name (as you’d like it to appear on your name badge): ______

Degree Tag (if you'd like it on your badge: M.A., Ph.D., etc.): ______

Affiliation (as you’d like it to appear on your name badge): ______

City, State, Country (as you’d like it to appear on your name badge): ______

Meal Preference: ___ non-vegetarian ___ vegetarian ___gluten free ___ kosher ___ vegan

Type of Certificate/ CE credits needed (please choose one for June 17-22):

____ no certificate needed

____ general certificate of attendance (no cost)

Fees, sign in and paperwork required for the certificates below:

____ general certificate of attendance with number of hours attended ($10, for all events June 17-22)

____ CEs for Psychologists (APA type) ($45, for all events June 17-22)

____ California LCSW or MFT CEs ($45, for all events June 17-22)

____ NBCC for counselors ($45, for all events June 17-22)

____ NASW for social workers - PENDING APPROVAL ($45, for all events June 17-22)

____ BCBA CEs ($8 per credit will be billed after conference)

License Number (if you need it to appear on your certificate): ______

Please note: CEs are only available with a Professional registration. Keep in mind that CEs require that all attendance requirements and evaluation paperwork be completed prior to receiving your certificate. This CE fee covers all CE events June 17-22, 2014 (pre-conference & conference). This fee is non-refundable (unless you cancel your registration in its entirety before the cancellation deadline).

Please total any fee required for certificates/CEs:

$______

For the World Conference (June 19-22, 2014)
Note: Above prices include 3 lunches, AM & PM coffee/tea on site, one dinner (June 19), and a general certificate of attendance.

Regular Reg. (ends May 30) / Onsite Registration
Professional / $579 / $629
Students / $329 / $379
Prof. Non ACBS Member / $639 / $689
Student Non ACBS Member / $359 / $409

Please circle your Registration Rate above, and list it here:

$______

For the Pre-Conference Workshops (June 17 & 18, 2014) (These workshops run concurrently; you may choose to attend only one 2-day workshop, or two 1-day workshops on separate days.)

Note: Prices below include lunch each day, AM & PM coffee/tea on site, and a general certificate of attendance.

Please mark the Pre-Conference workshop(s) you wish to attend (speakers listed):

2-Day Workshops (June 17 & 18): 1-Day Workshops (June 17): 1-Day Workshops (June 18):

____ Biglan, Embry, & Cairns ____ Bolderston & Gillanders ____ Coyne, Szymanski, & Egan Stack

____ Harris ____ Ciarrochi ____ Merwin & Moskovich

____ Presti, Miselli, & Stewart Curtin (CANCELLED) ____ Murrell & Al-Jabari

____ Schoendorff & Tirch ____ McKay & Zurita Ona ____ Törneke, Barnes-Holmes, & Luciano

____ Strosahl, Robinson, & Gustavsson ____ Polk & Burkhart ____ Vowles

____ Tsai, Kohlenberg, & Kanter ____ Twohig ____ Wright

____ Villatte, Villatte, & Batten

____ Walser

____ Wilson

Regular Reg. (Ends May 30) / Onsite Registration
2-day workshops (or two 1-day workshops) / 1-day workshop (June 17 or 18) / 2-day workshops (or two 1-day workshops) / 1-day workshop (June 17 or 18)
Professional / $379 / $229 / $429 / $279
Students / $229 / $155 / $279 / $205
Prof. Non ACBS Member / $439 / $289 / $489 / $339
Student Non ACBS Member / $259 / $185 / $309 / $235

Please circle your Pre-Conference Registration Rate above, and list it here:

$______

$______TOTAL (any CE/Certificate fee + conference + pre-conference workshop fee)

You may pay via Visa, MasterCard, American Express, PayPal, or by a check in US Dollars.

PayPal:

Go to

Our account is under the email address:

Credit Card:

If paying by credit card, you may mail or fax your registration to: 1(225) 302-8688

__Visa __MasterCard __American Express

No.______Expiry Date______Sec. Code ______

Signature:______

Checks:

Please make checks, in US Dollars, payable to ACBS.

Mail*, fax*, or email this completed form and payment to:

ACBS

1880 Pinegrove Dr.

Jenison, MI 49428

USA

1(225) 302-8688 (fax)

______

*If sent via regular mail or fax, this form and payment must reach ACBS in Jenison, Michigan, by June 2, 2014. After this date (but before June 13), you must email your registration or register online. After May 30, Onsite Registration Rates will apply.

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Note:
A $35 processing fee will be charged for World Conference & Pre-conference registration refunds up to June 2, 2014. (Per refund transaction.).We regret that after June 2, 2014, refunds cannot be made; however we will allow a substitute registrant. If you need a refund, please contact us via email.