<p> MentorCoach 7th Annual Conference Los Abrigados Resort Sedona, Arizona REGISTRATION FORM</p><p>Name: Address: Telephone: E-Mail: Title: Occupation: Preferred Contact Information: _ </p><p>Please check how you would like your coaching credentials listed: _____CMC ____ACC ____PCC ____MCC other: ______</p><p>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)</p><p>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.</p><p>CEU Certificate: ___ Yes ___ No ($75 additional fee)**</p><p>Check enclosed for: $______</p><p>Please charge my credit card: Card Number: Exp. Date: Type (MC, Visa, AmX): Cardholder Name: Authorized Signature: </p><p>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. </p><p>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].</p>