Counseling for the 21st Century: Tools, Trends & Technology
ONLINE REGISTRATION
TITLE: (Ex. Dr/Ms/Mr/Mrs/Miss)
Last Name: First Name:
Company/Organization:
Home Address:
Home City/State: Home Zip Code:
Email: Phone:
Are you a NYMHCA Member?
Membership Type:
If you are NOT a NYMHCA member, would you like membership material mailed to you?
Work Setting:
If you are a student, tell us the school you are attending:
Will this be your first time at a NYMHCA Convention?
Special Needs? (please specify):
There are 3 easy ways to register:
1.Email this to NYMHCA by clicking on the submit button at the bottom of this page.
2.Print off the printable form (click on button above) and fax them with credit card info to: 631-472-3866.
3.Print and mail to NYMHCA, 206 Greenbelt Parkway, Holbrook, New York 11741
*If you choose to process your credit card payment yourself please click on the button below. You will be directed to
ProfessionalCharges.com. NYMHCA uses the secure payment processing services of ProfessionalCharges.com to handle
online credit and debit transactions.
Early Registration(deadline 3/9/12)
Registration Fees
* There will be a $10 processing fee for on-site reg-istrations.
Full convention registrationincludes the Friday evening Dessert Reception with Panel Discussion, Concurrent Workshop Sessions and coffee breaks on Saturday and Sunday, plus the Saturday luncheon. It does not include the Saturday evening events. Your convention badge will serve as your admission ticket to all events.
Pre-Convention Workshop Registration:
Each workshop runs from 1-4 pm on Friday, April 20th, so select only one. The fee is $90. Click on "Convention Info" link above for more information about these workshops.
NBCC Credits:
Registration Subtotal: $
Workshop Subtotal (select one @ $90):
This convention is eligible for NBCC continuing education credits. Credits are provided for convention registrants who request them.Every registrant will receive a contact hour form in their folders.
Contribution to NYMHCA
Please consider making a contribution to help defray expenses related to our legislative agenda or to support our convention assistantship fund.
Optional Donation:
Donation: $
Total Amount Due:
Address as credit card company has it if it is different from above:
*If you process your credit card payment yourself, please then use your "BACK" button to return to this page, and click the SUBMIT button at the bottom so we receive your registration!!.
CVV is a 3-digit number printed on the signature panel on the back of your credit card. We cannot process your credit card payment without this number.
If you choose to print this form and mail or fax it to us, please provide us with the following information:
Method of Payment:
Credit Card Type:
Name on Card:
Credit Card Number:
Credit Card CVV#:
Expiration Date:
Questions? Please call (631) 472-3866 or 1-800-4-NYMHCA
If you prefer you can mail the printable registration form to:
NYMHCA
206 Greenbelt Parkway
Holbrook, NY 11741
Refund and Cancellation Policy :
NYMHCA will provide a full refund minus a processing fee of $40 for cancellations received in writing by April 1st, 2012.
No refunds will be issued after the April 1st deadline. Registrations may be transferred, but only to a person in the same registration category (for example: any NYMHCA member attending the full convention) and only if NYMHCA receives the request in writing by April 1st, 2012.
