Counselors Institute | Student Affairs

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Registration Form

15th Annual Counselors' Institute - January 22 - 24, 2009
Radisson Resort
South Padre Island, Texas

***Please view this form in Microsoft Internet Explorer. ***

To register for the institute fill out the information below and click the SUBMIT button to complete the online registration form.

For complete information about available payment methods click here.

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, 2009

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, 2008. For Daily Registration, please indicate which day.

PAYMENT METHODS FOR INSTITUTE ATTENDEES

There are 4 methods for paying the fees for the Counselors’ Institute.

1. CHECKS & MONEY ORDERS

· If you pay by check or money order, we prefer that you still register via our internet registration form.

· All check/money order payments must be in U.S. Dollars (USD) only.

· Make checks/money orders payable to UTB/TSC Counselors’ Institute and mail to the following address:

UTB/TSC

Attn: Student Success Center

80 Fort Brown

Brownsville, Texas 78520

· Please include attendees’ names and institute name with all mailed check/money order payments.

2. CREDIT CARDS

An additional processing fee will apply to payments made by credit cards, as shown below:

	Amount	Additional Fee
	$25	$3.00
	30	3.00
	50	4.00
	75	5.50
	100	6.50
	125	7.50

To pay by credit card online, please click here. Please note that the current default quantity is set to "2," so be sure to double-check how many registrations you select.

For Presenters Only: To pay the "presenter" rate, choose the attendee option, then click the "apply discount" button on the shopping cart screen. In the window that pops-up, select the rate labeled "presenter."

3. IDTs (INTERDEPARTMENTAL TRANSFER) are available for UTB/TSC Employees only

UTB/TSC employees who will be attending the Counselors’ Institute may prepare an IDT with their department name, list of employees attending the institute, account number, and account manager signature and route it to the Student Success Center office Attn: Letty Vega.

4. PAYMENTS BY PURCHASE ORDERS

If you choose to use this payment method, be sure to bring the purchase order number with you. UTB/TSC’s federal id # is 74-2759269

Please make checks payable to:

Attn: UTB/TSC

Student Success Center

80 Fort Brown

Brownsville, Texas 78520

Please note that all payments must be received by February 12, 2009.

Attendance receipt/invoice will be part of the program booklet.

For questions or problems regarding the registration process please contact Danny J. Perez at email: daniel.perez@utb.edu or at 882-7060.

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Print this form for your records before clicking "Submit."

	Licensed Professional Counselor (LPC)
	National Certified Counselor (NCC)
	Licensed Professional Counselor Intern
	Professional School Counselor
	Elementary
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	Administrator
	Private Practitioner
	Counselor Educator
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	Student
	Other (please specify)

Registration Type	Early Bird *Rec'd by 12/15/08	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	$50.00 - Thursday $25.00 - Friday $25.00 - Saturday Ethics Workshop	$
Presenter		No charge if presenting only	$50.00 - if staying for entire institute	$
			Registration Subtotal	$