43rd Clinical Conference
at Asilomar, June 6-8, 2008

Online Registration - Page 1 of 2

This form is for CONFERENCE registration only. Lodging reservations are handled separately.
Please refer to page 14 in brochure. Lodging reservation form must be mailed DIRECTLY TO ASILOMAR.

NOTE: TO RECEIVE EARLY REGISTRATION PRICING, BOTH CONFERENCE
REGISTRATION AND HOUSING APPLICATION (VIA MAIL) MUST BE SUBMITTED BY APRIL 1.

NOTE: If you do not wish to register online, print out and mail the form on page 15 of the downloadable brochure
along with a check for payment in full. (Credit card payments accepted online only.)


For additional information about the conference, contact Institute Co-director Rose Phelps, MFT

	General Information
	Last Name: Degree BA EdD MA MD MS MSN MSW PhD PsyD First Name: Name for Badge: Age: Sex M F Address: City : State California Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska New Hampshire Nevada New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Phone (day): (eve): (cel): Email: Required Employer: NCGPS Membership: Select One Current NCGPS Member (dues paid in full) NCGPS Member, need to renew (for reduced registration fee) NOT an NCGPS member, wish to join (for reduced registration fee) NOT an NCGPS member How did you hear about this event? Group Therapy Experience: Years Leading Groups: Years in the Field:
	Section Preferences For each day, please indicate 3 choices in order of preference. If you choose either of the two 3-day process groups (A or B), be sure to enter that choice in all three days for that choice level (1st, 2nd or 3rd). Saturday all day: First Choice B C D E F G H I J K L Second Choice B C D E F G H I J K L Third Choice B C D E F G H I J K L Sunday morning: First Choice M N O P Q R S T U V W X Second Choice M N O P Q R S T U V W X Third Choice M N O P Q R S T U V W X Check here if to affirm that you have read the brochure and agree to adhere to the Conference Contract stated on page 10. Check here if you are not staying on Asilomar grounds and would like information regarding on-campus meals at Asilomar

Click button above to submit Registration Application
and proceed to next page to pay Registration Fees.