REGISTRATION FORM

LCA 2018 Annual Conference October 7-9, 2018 353 Leo Shreveport, LA 71105 Pre-conference Learning Institutes (Separate Rates Apply forLI) October 6, 2018 Fax: 318 868 3580 Baton Rouge Crown Plaza Hotel

There is a discount for registering online)

Name (Print) ______(first) (middle initial) (last) Nick Name for Badge: (if applicable otherwise First name will be used.) ______

Mailing Address ______

City ______State______Zip ______

Daytime Phone ( ) ______Evening Phone ( ) ______

E-mail ______

Pursuant to the America with Disabilities Act, do you require assistance? (This request must be received prior to September 8. After this date LCA may not be able to provide the needed accommodations? Please indicate the accommodations being requested. ______

If you are a student, please indicate your university. ______

T-Shirt Size ______(Available only to membersregistering for a full conference andmeeting the Advanced Registration Deadline)

Primary Division: Please circle your primary division (only one, please) LACES LCDA LASERVIC LCCA LAMCD LMHCA LSCA LAMFC LAAOC LCSJ ALGBTIC LACGS PLCA

******Printed Conference Programs: Cost of Printed Program $5.00 ______yes _____no I plan to use the conference app and do not need a printed program. Tickets will be issued to pick up the printed program IF PAID FOR.

LCA Mugs: Order now for pick-up @ conference $5.00______yes

Join or renew LCA membership and a division to save up to 40% on Registration Fees.

Registration Fees may be paid with check, money order, cash, purchase order, or credit card during the Advanced and Pre-registration periods. LCA NO LONGER accepts PERSONAL CHECKS on site.

Refund Policy: Cancellation requests MUST be made in writing by email or US post. Requests received by September 13 will incur an administrative charge of $50.00; those received after September 13 but prior to September 28 will incur an administrative charge of $75.00 subtracted from the registration fees received. NO REFUNDS AFTER OCTOBER 1.

Brown Bag Lunches: Brown Bag lunches (sandwich, chips, drink) will be available Sunday, Monday and Tuesday. $10.00 each day. Purchase prior to conference to ensure availability.

______Sunday ______Monday ______Tuesday Subtotal: ______

PRE-CONFERENCE LEARNING INSTITUTES

Advanced Registration / Pre-Registration/Onsite / Available Workshops
(Indicate your Choice)
LCA Members / 3-hr $50.00 / 6-hr $100.00 / 3-hr 50.00 / 6-hr $100.00 / Reading the Tell: Body Language 3.0
Future of Work 3.0
Learning to use the Tools: Calocus and Locus 6.0
Discernment Counseling 6.0
Crisis Intervention and Recovery 6.0
Non-Members / 3-hr $100.00 / 6 hr $ 150.00 / 3-hr. $100.00 / 6-hr. $150.00

Subtotal $______

Conference Rates (Full conference) / Advanced until 8/25/2017 / Pre-Registration 8/25-9/14 / Onsite Registration 9/14-10/09
LCA Professional/Reg. / $310.00 / $330.00 / $350.00
One Day / $150.00 / $180.00 / $210.00
Two Days / $285.00 / $310.00 / $330.00
LCA Student Member / $125.00 / $145.00 / $180.00
One Day / $70.00 / $95.00 / $115.00
Two Days / $90.00 / $110.00 / $135.00
LCA PLPC Member / $125.00 / $150.00 / $180.00
One Day / $70.00 / $95.00 / $115.00
Two Days / $90.00 / $110.00 / $135.00
LCA Retired Member / $125.00 / $150.00 / $180.00
One Day / $70.00 / $95.00 / $115.00
Two Days / $90.00 / $110.00 / $135.00
Non-Member / $450.00 / $450.00 / $500.00
One Day / $265.00 / $265.00 / $300.00
Two Days / $350.00 / $350.00 / $400.00

Subtotal $______

4. I would like to contribute to the LCA Community Project $______

5. Additional Meal Functions

Sunday, October 1

LSCA 30.00

Monday, October 2 LMHCA 35.00

LACES35.00

LCCA 18.00 Tuesday, October 3

LASERVIC35.00

LAMCD35.00

LAMFC35.00

LAAOC0.00

Subtotal_____

____I have purchased a meal and will need a specially prepared menu. Request must be received by 9/20. My needs are: ______Payment Method (Full payment must be enclosed or registration will not be processed)

_____Check or money order payable to Louisiana Counseling Associations (LCA)

_____Purchase Order (purchase order form must be included) guidelines for using a Purchase Order may be found on the webpage

_____VISA ____ Master Card _____Discoverer ____American Express

Credit Card Number______Exp. Date ______

CVC Code Amex: _ _ _ _ Visa Master Card Discover _ _ _

Cardholder’s Name (print)______

Authorized Signature______

The Louisiana Counseling Association has been approved by NBCC as an Approved Continuing Education Provider, ACEP #2019. Programs that do not qualify for NBCC credit are clearly identified. LCA is solely responsible for all aspects of the program.