Conference 2000 Fax/Mail Registration Form

5th Annual Child Abuse Prevention Conference
On The Front Lines-For The Children
April 2-4, 2000 Albany Marriott Albany, New York
FAX/MAIL REGISTRATION FORM

PRINT
AND FILL OUT THIS FORM FOR EACH REGISTRANT
INTERNET REGISTRATION?
check soon!

CLICK HERE! TO REVIEW THE CONFERENCE

Please use a separate form
for each person registering. Photocopy as needed. Please print
or type. Thank you.
Return with check, purchase order or credit card number. (Registration
does NOT include hotel reservation.)


MAIL: NCPCA- NYS, 134 South Swan Street,
Albany, NY 12210
FAX: 518-436-5889 (Credit card payment only) Inquiries: 518-445-1273
/ [email protected]

Name ____________________________________________________(please PRINT as it should appear on
nametag)

StreetAddress_____________________________________________/Agency
__________________________________________

City________________________________________/State____/Zip_______________/County:___________________________

Phone ______________________/Fax_____________________/E-Mail__________________________
Check here if you do NOT
want your name to appear on the Participant’s List that is
enclosed in conference packets: ___

Special Needs: Communication____ Mobility____ Please
specify need:____________________________________Special Meals:
Kosher____ Vegetarian____ Diabetic____

Conference Registration
Fees:

PAYMENT: [Total
Payment $ _____________ ]
Please CIRCLE the fee
that applies to you*———>

Check, payable to NCPCA-NYS, # ___________
]

Purchase Order # __________________________ ]
CREDIT CARD: Mastercard __ VISA __

Card # _______________________Exp/____/_____/

Name on card____________________________

Signature: ______________________________________

CANCELLATION: Refunds less
a $20/person processing fee, will be issued ONLY for written
cancellations postmarked or faxed by Monday, March 2, 2000. NO-SHOWS
will be billed.

*SAVE
NOW- REGISTER BY February 29, 2000!

FULL CONFERENCE

By 2/29

Early Bird

$175

After
2/29

$200

nn

nn

nn

ONE DAY: Check
day:

Monday

Tuesday

By 2/29

$90

As of
2/29

$100

nn

$90

$100

Sunday
Only

By 2/29

$70

After
2/29

$80

nn

$70

$ 80


 
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