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2015 Conference Registration - June 3, 4, 5
Hosted by Le Moyne College & Syracuse University
Last Name
First Name
Email
College/ University
Dietary Restrictions
Disability:
If you require assistance to participate in this conference, please email your needs to Hattie
Haresky at hharesky@syr.edu. (participants will be walking between buildings on campus)
___________________________________________________________________________________________________________________________________________
Pre-Conference Workshop Registration -Wednesday, June 3rd, 9:00 am - 4:30 pm
"Explorations on Creating and Sustaining a Group Therapy Culture after Successfully Launching a Group" - Dr. Ian Birky & Dr. Nicole Ruzek
Pre-Conference Workshop - $85.00..(SOLD OUT)
Conference Registration - Thursday, June 4th & Friday, June 5th
Professional Registration - $130.00 ...................................................................................................................$
Student Registration (valid student ID required) - $95.00 ................................................................................$
YES
NO
Attending the Reception & Dinner at the Sheraton Hotel Ballroom on Thursday, 6/4 at 5:30PM-9:30PM
Tues Wed Thur
6/2
6/3
6/4
Single room (includes linens) - $50.00 x # of nights + ($12 linen pack).............................................................$
Campus Lodging - Ernie Davis Residence Hall
Double room (includes 2 sets of linens) - $60.00 x # of nights + ($24 linen packs) =.......................................$
Parking
Roommate's name:
(4) Day Parking: Staying at Ernie Davis...checking in Tuesday 6/2, checking out Friday 6/5 - $20.00..........$
(3) Day Parking: Staying at Ernie Davis...checking in Wednesday 6/3, checking out Friday 6/5 - $15.00.....$
(3) Day Parking: Wednesday 6/3, Thursday 6/4, Friday 6/5 - $15.00..............................................................$
(2) Day Parking: Thursday 6/4, Friday 6/5 - $10.00.........................................................................................$
Handicap parking needed. (Check and add in days needed above).
Total Amount Due $ $ 0.00
Payment: Check or Copy of Purchase Order must accompany registration form. We can NOT accept Credit Card payment.
Check enclosed. Check#:
PO enclosed. PO#:
Payable to: Syracuse University
Mail to: Syracuse University Counseling Center
200 Walnut Place
Syracuse, NY 13244
Payment must accompany Registration Form
Registration Deadline: May 1, 2015