REGISTRATION FORM 11th Annual Forum on the State of Counseling and Guidance in Schools
University of San Diego Ù December 11, 2009 Use this form if you are paying by PO or check. One registrant per form. Please print clearly. 1. REGISTRANT INFORMATION
USING A CREDIT CARD? REGISTER ONLINE WWW.SANDIEGO.EDU/CS3/EVENTS
EACH REGISTRANT MUST COMPLETE A SEPARATE REGISTRATION FORM
FIRST NAME: _______________________ LAST NAME: _________________________________ ADDRESS: ___________________________________ CITY: _____________________________ STATE: __________ ZIP: _____________ PHONE: ____________________________________ EMAIL ADDRESS: ________________________________________________________________ POSITION TITLE: _________________________________________________________________ NAME OF SCHOOL/PLACE OF EMPLOYMENT: ________________________________________ LEVEL: Elementary
Middle
High
District Adult
Post Secondary
Other
If Graduate Student: UNIVERSITY: __________________________________________
2. EVENT REGISTRATION Fee includes continental breakfast, lunch, coffee breaks, keynote presentation and all sessions before November 1st
after November 1st
Professional
$70
$95
$ __________
SDCASC*
$55
$75
$ __________
Graduate Student*
$25
$35
$ __________
*must show proof of membership or student ID
3. PAYMENT Check enclosed, payable to USD - CS3 Check #: ___________________ Date: _______________ Amount: $__________ Purchase order enclosed, payable to USD - CS3 PO #: ___________________ Date: _______________ Amount: $_____________________ District or School: ____________________________________________________________ Address: ___________________________________________________________________ City: _______________ State: __________ District Contact Person: ________________________________________________________ Phone: _______________________________
Fax: ________________________________
4. SUBMISSION Mail registration form with payment to: University of San Diego - CS3 5998 Alcalá Park, MRH 143 San Diego, CA 92110 Fax (619) 849-8143 (for forms with PO only) Phone (619) 260-7708