Registration

Registration—2010 Annual Conference of the North Central Region-ACPE

Chula Vista Resort, Wisconsin Dells, WI

3:30 p.m. Sunday, October 10 through 12:00 p.m. Tuesday, October 12

Until September 10th, there is an early registration fee of $100.00 for this conference for active CPE Supervisors (including Candidates), Clinical Members, and Faith Group and Seminary Representatives, and a $75.00 early registration fee for Supervisory Education Students and retired CPE supervisors that covers meals and lodging. 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 $44.50 per night. You will be reimbursed for travel according to the formula published with the conference schedule. Registrations received after September 10th will be assessed a late fee of $25.00. Family Members & Guests pay the actual cost for rooms and meals.

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 (includes Candidates) / Sem Rep / Faith Group Rep / Clinical Member

Supervisory Education Student / Retired Supervisor

    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.

d. :

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
Lodging Friday Night, October 08 Cost covered personally or by NCR committee budget
Lodging Saturday Night, October 09 Cost covered personally or by NCR committee budget
Sunday Supper Buffet						$21.95 / $13.25
Lodging Sunday Night, October 10
Monday Breakfast						$10.95 / $6.75
Monday Lunch						$12.95 / $7.75
Monday Evening Banquet
London Broil						$19.00
Chicken Cordon Bleu						$19.00
Squash & Pepper Tortellini						$19.00
Kid's Meal (Chicken Fingers & Fries)						$8.95
Lodging Monday Night, October 19
Tuesday Breakfast						$10.95 / $6.75

If you need to chancel or change any part of this registration, please do so through the Regional Office only: 612-270-3313; ncracpe@ncracpe.org Do not attempt to do it directly through the hotel. Please also contact the Regional office if you hae questions or needs that go beyond the parameters of this registration form such as additional nights; cribs or cots in your room, handicap rooms, etc.

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