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COUNSELORS' INSTITUTE REGISTRATION FORM

14th Annual Counselors' Institute - January 24 - 26, 2008
Radisson Resort
South Padre Island, Texas

1. PERSONAL INFORMATION

First Name
Last Name
Job Title
Institution / Organization
Mailing Address
City
State / Country
Zip / Postal Code
Daytime Telephone Number
E-Mail
Accessible Services: Please specify accessible services you require by January 15, 2008

Please check all items below that apply

Work Information

Institution / Organization
Work Address
City
State
Zip / Postal Code
Work Phone
Fax
E-Mail

2. INSTITUTE REGISTRATION

Early-bird registration rates apply if conference registration form and payment are received by December 15, 2007. For Daily Registration, please indicate which day.

Payment Methods:

By Mail:
    Maria Diaz-Garcia
    P.O. Box 4045
    McAllen, TX
    78502-4045

Personal Checks, Business Checks or Purchase Orders will be accepted. Make checks payable to "Counselors' Institute".

*We do not have credit card capabilities. Cancellation requests will no be accepted after January 14th, 2008. Please allow 6-8 weeks for reimbursement.

	Licensed Professional Counselor (LPC)
	National Certified Counselor (NCC)
	Licensed Professional Counselor Intern
	Professional School Counselor
	Elementary
	Middle School
	High School
	College University
	Administrator
	Private Practitioner
	Counselor Educator
	Social Worker
	Student
	Other (please specify)

Registration Type	Early Bird *Rec'd by 12/15/07	On-Site	Daily / Day Rates *Indicate Date	Amount Paid
Attendee:	$100.00	$125.00	$75.00 - Thursday $50.00 - Friday $50.00 - Saturday Ethics Workshop	$
*Guests Dinner only**			$30.00 - Thursday Dinner	$
Student *Please fax Student ID to (956) 882-8294 Attn: Dr. Becerra	$50.00	$65.00	$25.00 - Thursday $25.00 - Friday $25.00 - Saturday Ethics Workshop	$
Presenter		No charge if presenting only	$50.00 - if staying for entire institute	$
			Registration Subtotal	$