Registration

Registration—2008 Annual Conference of the North Central Region-ACPE

Chula Vista Resort, Wisconsin Dells, WI

4:00 p.m. Sunday, May 18 through 11:30 a.m. Tuesday, May 20

Certified Supervisors (Candidate through Retired), Seminary & Faith Group Representatives, Clinical Members, and Supervisory Education Students: There is a flat registration fee for this conference that includes meals and lodging. The fee is $60.00 for registrations postmarked April 15th or earlier and $75.00 for registrations postmarked after April 15th. This is predicated on your sharing a room with another registrant. If you request a private room or choose to have family members or other guests in your room with you, your cost will be the base fee plus an additional $37.50 per night. You will be reimbursed for travel according to the formula published with the conference schedule.

Family Members & Guests pay the actual cost for rooms and meals. Room costs are $37.50 per night if you share a room with another registrant. If you request a private room or choose to have family members or other guests in your room with you, the cost will be $75.00 per night.

Fill out this form completely, attending carefully to each numbered section.

Use your mouse or the tab key to move from section to section (not the "Enter" key).

Review your input carefully and make any corrections before clicking on the "Submit" button once.

If you realize you made an error after submitting your registration, simply re-submit a corrected version.
The results come to the regional office as an email. We will always honor the later submission.

If you do not receive email confirmation or an invoice within a reasonable time after your submission, please contact the Regional office.

Please do not send payment until invoiced.

1. Registrant...

Name

Address Line 1

Address Line 2

E-mail

Phone #

Non-attending Emergency Contact

Phone #

2. Registration Category...

Certified Supervisor / Sem Rep / Faith Group Rep / Clinical Member

Supervisory Education Student

    Guest requiring own room or requesting an assigned roommate
          (Family members and people attending as guests of registrants who will stay in the room of a
           registrant do not need to fill out a registration form. They will be covered through sections 4 & 5
           of the registrant's form.)

3. Room Needs...

All rooms in our block will have two beds. Please list your room needs here by checking the appropriate spot on each line & filling in the related boxes:

a. Request Non-Smoking room or Request Smoking room

b. Request Roommate or Request Private room / room with family

(If requesting a roommate, fill out the remaining items in this section, otherwise go to Section 4.)

c. My first choice for a roommate is

My second choice for a roommate is

d. Assign a roommate at your discretion
(If I don't choose one or my choice(s) are not available, or

I prefer a private room if my requested roommate(s) are not available.
(Additional cost of $37.50 per night.)

4. Section for Registrants with Family Members or Guests Staying in their Room...

(If you do not have family members or guests staying with you, skip this section and go to #5 and select items in the "Registrant" column only.)

If family members or friends will attend the conference with you and share your room, please list their name(s) here. Write the ages of children after their names. Then go to section 5 and check off all items needed by each person, including yourself.

5. Meal Selections...

Note: Even if you are a flat rate registrant, it is important that you check off only the particular items below that you will be using, as the Region does not want to pay for rooms that are not inhabited or meals that are not going to be eaten. We are required to guarantee room numbers 24 hours in advance of the conference and meal numbers three business days in advance of the conference. We will be charged for no fewer meals than the guarantee, and can go over by no more than 3#. This makes accurate counts vital.

	Registrant	Person a.	Person b.	Person c.	Person d.	Costs
						Adult / Child 4-12
Sunday Supper Buffet						$18.50 / $11.10
Lodging Sunday Night, May 18
Monday Breakfast						$8.00 / $4.80
Monday Lunch						$9.00 / $5.40
Monday Evening Banquet
London Broil						$18.95
Chicken Viennese						$18.95
Squash & Pepper Tortellini el Pesto						$18.95
Kid's Meal (Chicken Fingers & Fries)						$8.95
Lodging Monday Night, May19
Tuesday Breakfast						$8.00 / $4.80
Tuesday Box Lunch						$9.00

If you need to chancel or change any part of this registration, please do so through the Regional Office only. Do not attempt to do it directly through the hotel.

Please review the form carefully before clicking on the "Submit" button once.