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Mental Health Seminar
 


Correctional Mental Health: From Innovation to Practice
Las Vegas, Nevada l July 13 - 14, 2008
Registration Form
 

Online registration is closed.
Please register on-site at the conference.

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Step 1 - Name/Address
Fields in red are required for online registration. Please use the "tab" key to move from field to field; if you hit "enter" your form may be submitted prematurely.
 
First Name
Last Name
Gender
Degree
Professional Title
Organization/Affiliation
Address
City   
State/Province  
Zip/Postal Code   
Country  
Is this address for work or home?
Daytime Phone
Fax
E-mail Address

We periodically send conference or other information via e-mail.
If you do not wish to receive such information, please check here.

In what type of facility do you work?   
If "other," please indicate facility type.

Is this your first NCCHC meeting?
Step 2 - Academy Membership

Members of the Academy of Correctional Health Professionals receive a members-only discount on conference registration. To take advantage of this discount, simply indicate that you would like to join the Academy and include the $75 membership dues in your conference registration fees. To learn more about the benefits of membership, visit the Academy Web site.

Step 3 - Registration
Academy of Correctional Health Professionals Membership
CCHPs already are Academy members and cannot use this form to renew certification or membership.

Seminar Registration Fees
Full registration fees include activities from
9 am Sunday through 4 pm Monday.


If you selected "Member Registration," please provide Member ID # or write "New Member" if you are just joining.


Conference Badge Information
Provide the information to appear on your badge, unless it is the same as shown above.
Information same as above
Information differs (complete fields at right)

Name   

Affiliation           

City, State

Guest Registration
For guests of registered attendees only.
Provides access to all exhibit hall functions.


If you are registering a guest, please indicate the name to appear on the badge.


Step 4 - Academy Activities
 Mental Health Roundtable Discussions Free
Step 5 - Payment
Invoice Processing Fee
Purchase orders accepted only from government agencies and their contractors. Purchase order must accompany registration.		 $15
Total Payment Amount $
Credit Card Information (Required to register online)

     Cardholder Name                     Card Type
              

     Credit Card Account Number    Expiration Date (mm/yyyy)
            

      V code (3 digits in card signature box; does not apply to AmEx)   

  
Checks and Invoices

If paying by check or invoice*, please print this form and mail it with your payment or purchase order.  Indicate check or purchase order number.

* Purchase orders accepted only from government agencies and their contractors. Purchase order must accompany registration. There is a $15 service charge for invoice processing.

Mail to: NCCHC, Conference Registration, P.O. Box 11117, Chicago, IL  60611

Federal Employee Identification Number 36-3221830
Billing Address (if different from registration address above)
Cardholder
Address
City   State/Province  
Zip/Postal Code

Click here to view our Cancellation Policy.

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