Registration Form s3

Registration Form

LOUISIANA COUNSELING ASSOCIATION 2016 ANNUAL CONFERENCE Crown Plaza Hotel, Baton Rouge, Louisiana 353 Leo, Shreveport, LA 71105 318 861-0657 fax: 318 868-3341 [email protected]

Pre-Conference Workshops, September 24; Conference Sessions, September 25-27

1. Registration Information

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 the September 10. After this date LCA may not be able to provide the needed accommodations? ______

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

T-Shirt Size ______(Available only to those full conference members meeting 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, PLCA

Join or renew LCA membership and a division to save 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 24 will incur an administrative charge of $75.00 subtracted from the registration fees received. NO REFUNDS AFTER SEPTEMBER 24. 2. Pre-Conference Workshops Please indicate if you are planning to attend a pre-conference workshop: September 26, 2015 Pre-Conference Workshops LCA Non-LCA Member Member

Technology Related Issues and Tips in School Counseling 9:30-12:45 $40.00 $50.00

Youth Suicide: Prevention and Intervention (2:00-5:15) $40.00 $50.00

Raising the Bar: Critical New Concepts in the 2014 ACA Code of Ethics (all day) $80.00 $100.00

Mind Full or Mindful? Enhancing Your Own Presence in this Moment: $80.00 $100.00 Guiding Clients to do the Same (All day)

Dyadic Relationship Based Therapy: Essential Strategies and Ethical $80.00 $100.00 Considerations (all day)

NASP Prepare Workshop 1: Crisis Prevention and Preparation (all day) $80.00 $100.00

Subtotal $______

3. Conference Registration

Registrations completed online receive a discount. Please Mark the appropriate registration status. If appropriate fee is not included, registration will be held at the Problem Desk at conference. Remember online prices are discounted. Please consider registering online www.lacounseling.org

* Must be a member to received discounted fees as a student, retired, or PLCA.

Received in the LCA Advanced Pre-Registration On-site not available Office Registration By September 12 online By August 15 Beginning September 13 LCA Member ____Professional $290.00 $310.00 $330.00 ____Professional 1-day $155.00 $180.00 $200.00 ____Professional 2-day $280.00 $300.00 $320.00 ___*Student Member $130.00 $150.00 $170.00 ___*Student 1-day $80.00 $105.00 $95.00 ___*Student 2-day $100.00 $120.00 $110.00 ___*Retired member $130.00 $150.00 $170.00 ___*Retired 1-day $80.00 $105.00 $95.00 ___*Retired 2-day $100.00 $120.00 $110.00 ___*PLPC member $130.00 $150.00 $170.00 ___*PLPC 1-day $80.00 $105.00 $95.00 ___*PLPC 2-day $100.00 120.00 $110.00 Non Member ____General Attendee ____$450.00 ____$450.00 ____$500.00 ____1-day ____$250.00 ____$250.00 ____$300.00 ____2-day ____$350.00 ____$350.00 ____$400.00

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

5. Additional Meal Functions (Onsite Luncheon prices $35.00)

Sunday, September 25

LSCA 35.00

Monday, September 26 Amount due: LMHCA 35.00

LACES 35.00

Tuesday, September 27

LASERVIC 35.00

LAMCD 35.00

LAMFC 35.00

Subtotal_____

TOTAL PAYMENT ENCLOSED ______

____I have purchased a meal and will need a specially prepared menu. Request must be received by 9/12. 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 http://www.lacounseling.org/lca/Registration.asp

_____VISA ____ Master Card _____Discoverer ____American Express

Credit Card Number______Exp. Date ______

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

Cardholder’s Name (print)______

Authorized Signature______