Name: ____________________________________

Address: __________________________________

Phone: ________________Fax: _______________

Email: ____________________________________

Conference Fee                         $ __________

Certificate for Contact Hours                                                                  for Social Workers ($10)            $ __________

Certificate for Contact Hours                                                                  for Nurses ($10)                         $ __________

DISCOUNT! Take $15 off per person if registered with 3 or more people from your agency (must be registered at the same time).
                       Less discount      $ __________

                       Total                    $ __________

___ Check Enclosed    ___Visa      ___ MasterCard
        ___ Discover         ___ American Express 

CC No._____________________________

Expiration date___________

Signature___________________________________

Purchase Orders Welcome! (complete information below)

PO# __________  Phone: __________________

Contact: _________________________________

Address: _________________________________
Submittal of registration form is your agreement to SWSSC Conference Policies.

Note: Cost of registration includes Pre-conference & Keynote and Membership dues for the year 07-08.

Advance Registration:
(Advance Registration closes April 18, 2007)

$175 SWSSC/PPAT Member
$195 Non-member

Late or Onsite Registration:
(registration after April 18, 2007)

$195  SWSSC/PPAT Member
$215  Non-member

DISCOUNT:  Take $15 off per person if you are sending 3 or more individuals (Must be registered at the same time).

Cancellation Policy  No refunds will be given after April 18, 2007; however substitutions will be permitted.

Questions??

Call Roxann Bingham or John Akers @ 817-558-9559