NYMHCA April 20-22nd, 2012 Convention
Albany, NY
Counseling for the 21st Century: Tools, Trends & Technology
Convention Registration Form
Name :___________________________________________________________________________
Organization:______________________________________________________________________
Street Address:____________________________________________________________________
City/State:__________ County__________________ Zip:__________
Phone:__________________________Email:_________________________
I require special accessibility accommodations as follows: ___________________________________________________________
*Students must be half-time or more. Enclose a photocopy of student ID or advisor’s signature with your registration.
Registration Subtotal:__________
Pre-Convention Workshops:
___
~ Private Practice Plugged In: Ethical Online Business Strategies for Psychotherapist - Susan Giurleo
___ ~ Distance Counseling Certification Training - Deanna Merz-Nagel (registration is not done through NYMHCA)
___ ~ Licensure 101: Everything you need to know to become Licensed - Paul Schwartzman
___ ~ Meditation, Counseling and the New Brain Research - Richard Schaub
___ ~ Seven Steps to Freedom in Private Practice - Dr. Deborah Legge
Workshop Subtotal (One @ $90)_________
NBCC Credits: This convention is eligible for NBCC continuing education credits. Credits are awarded to convention registrants at the end of the convention. Every registrant will receive a CEU (contact hour) form in their folders.
NYMHCA Membership: If you are not a NYMHCA member and would like to join in order to receive free NBCC credits and other membership benefits, you may enroll by going to our homepage and clicking on the “Join NYMHCA” button. You can also request that membership material be sent to you.
_____Please send me membership material by mail.
Please choose your Saturday luncheon meal: _Chicken (chicken breast with artichokes and lemon butter sauce)
____ Rainbow Tortellini (Ricotta filled tortellini with roasted garlic in alfredo sauce)
* If you have special dietary requirements of need more information about the menu, please call our office.
NYMHCA Contribution: Please consider making a contribution to help defray our operating expenses or to support our convention scholarship fund for those on limited budgets.
Option Donation for: ___NYMHCA PAC ___Convention Assistantship Fund $_________
.Total Amount Due (add subtotals) $__________
_
___ Enclosed is a check payable to NYMHCA.
____Please charge to my (VISA/Mastercard/Discover) account.
Name as it appear on card________________________________Card Number_________________________
CVV # _______ 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.
Expiration Date______________Authorized Signature_____________________________________
Mail to: NYMHCA, 206 Greenbelt Parkway, Holbrook, NY 11741
Or Fax to: 631-472-3866
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.
