Mentorcoach 7Th Annual Conference Los Abrigados Resort Sedona, Arizona

MentorCoach 7th Annual Conference Los Abrigados Resort Sedona, Arizona REGISTRATION FORM

Name: Address: Telephone: E-Mail: Title: Occupation: Preferred Contact Information: _

Please check how you would like your coaching credentials listed: _____CMC ____ACC ____PCC ____MCC other: ______

Please reserve ____ spots at:  $350(early bird by December 31, 2008)  $395(advance -- After December 31, 2008)  $65 (extra guest for Friday evening dinner party)

Registration includes Thursday evening Ice Breaker with Ben Dean, Friday and Saturday workshops/presentations, Saturday and Sunday breakfast, and dinner & dancing party on Friday night.

CEU Certificate: ___ Yes ___ No ($75 additional fee)**

Check enclosed for: $______

Please charge my credit card: Card Number: Exp. Date: Type (MC, Visa, AmX): Cardholder Name: Authorized Signature:

American Psychological Association (APA) -- MentorCoach is approved to distribute at the end of the conference on behalf of the APA 11 CE credits and 11 contact hours. National Board of Certified Counselors (NBCC) -- MentorCoach is approved to distribute at the end of the conference on behalf of the NBCC 1.1 CEUs and 11 contact hours. California Board of Behavioral Sciences (CA BBS) -- MentorCoach is approved to distribute at the end of the conference on behalf of the CA BBS 11 CE hours. National Association of Social Workers (NASW) -- MentorCoach is approved to distribute at the end of the conference on behalf of the NASW 11 contact hours (PENDING APPLICATION APPROVAL). International Coach Federation (ICF) -- MentorCoach is approved to distribute at the end of the conference on behalf of the ICF 11 Coach Continuing Education hours.

Please send completed form as soon as possible as space is limited to: MentorCoach LLC, 4400 East West Hwy/Suite 1104, Bethesda, MD 20814. Fax to (301) 913-9447 or e-mail to [email protected].