Registration Form

 

The Multicultural Play Therapy Conference at UNC Charlotte

June 25 - 28, 2012

 

8:30 a.m. to 4:00 p.m.

 

UNC Charlotte

 

 

Home        Student Verification Form    

 

Pre-Registration Deadline

June 18, 2012

 

Please provide the following requested information.

 

Dr.    Mr.    Ms.    Mrs.

First Name:       MI: 

Last Name:   

Email:   

Mailing Address:   

City:   

State:   

Zip:   

Home Telephone Number:   

Cell Telephone Number:                  

Employer/Institution:   

Organization/Affiliation: 

Occupation (if applicable): 

License (if applicable): 

Work Telephone Number:   

Fax Number:   

Are you a student?    Yes        No   
If so, please provide the institution you are currently enrolled

Please tell us how you became aware of the Multicultural Play Therapy Center Conference:

Please indicate below if you would like to receive NBCC (LPC) or RPT continuing education credit. 
     NBCC (LPC):   Yes       No
     RPT:     Yes       No

Please indicate the session(s) you will attend:
June 25, TheraplayŽ: An Attachment-Based Play Therapy by Ms. Phyllis Booth
June 26, TheraplayŽ: An Attachment-Based Play Therapy continued by Ms. Phyllis Booth
June 27, Ethical Decision-Making in Play Therapy: Models and Applications by Dr. Jeff Ashby
June 28,Understanding the Role of Play in Trauma Focused Cognitive Behavioral Therapy by Ms. Angie Nance

Please indicate your total registration payment below:

Professionals

Students

Please complete the Student Verification Form and submit with payment.
$100.00 for one day       $50 for one day
$190.00 for two days  $100 for two days
$280.00 for three days $150 for three days
$370.00 for four days $200 for four days

A link is available on the confirmation page for credit card payments after completing this form and clicking "Submit" below.  Please make checks payable to UNC Charlotte.  If your registration fee is to be paid by your company or sponsor, please provide the information requested below for an invoice:  

Registration Fee Total:          Check#PO#Mo#:      

Billing Contact:                      Email:                        

Address:                               Phone:                                

City:                                   

State:                         

Zip:                                    

If you are paying by check or money order, please mail a copy of your confirmation form with your payment to:

Office of Educational Outreach
College of Education
University of North Carolina at Charlotte
9201 University City Blvd.
Charlotte, NC  28223
Telephone:  (704) 687-8801
Fax:  (704) 687-6289
Email:  vbmack@uncc.edu

Please print the confirmation page after clicking the "Submit" button below.  Please bring a copy of the confirmation page to the registration table at the Health and Human Services Building when you report to the conference.  Thank you.