Let YourStar Shine Bright... Let Your Star Shine ... - Child Life Council

How to RegisterThere are two easy ways to registerfor the 2006 Annual Conference:1. Fax BOTH PAGES of thiscompleted registration form withcredit card information to301-881-7092 (if you are faxing,please do not mail the originalas well); OR2. Mail this completed registrationform with check, money order orcredit card information to:2006 Annual ConferenceChild Life Council11820 Parklawn Dr., Suite 240Rockville, MD 20852-2529ANNUAL CONFERENCE REGISTRATION FORM – Part 1REGISTRATION INFORMATIONLast Name: First Name: M.I.First Name as it Should Appear on Badge:Organization:Address: WorkHomeJob Title:City: State/Province: Zip/Postal Code: Country:Daytime Phone:Email Address:Fax Number:SPECIAL NEEDS (please submit no later than April 3, 2006; include description below and a CLC staff member will contact you): Dietary Physical OtherDescription:EMERGENCY CONTACT INFORMATION (required):Contact Name:Relationship:Daytime Phone: Evening Phone: Mobile Phone:MEMBERSHIP STATUS (check one): Active Member Student Member Associate Member Corporate Member Lifetime Member Non-Member Student Non-Member Honorary MemberCLC DESIGNATIONS (check all that apply): Certified Child Life Specialist (CCLS) First-Time Attendee Speaker/Presenter Board Member Committee Member Committee Chair Networking Facilitator Exhibitor SponsorCONFERENCE EVENTS I PLAN TO ATTEND (included with basic registration - check all that apply):Thursday, May 25 Friday, May 26 Academic Member Networking Meeting, 5:15pm – 7:00pm Speakers’ Breakfast Meeting (Speakers Only), 7:30am – 8:30am New Member/First-timer Orientation Session, 5:30pm – 6:30pm Student Breakfast (Students Only), 7:30am – 9:00amFinancial & Self Care Seminars, 8:00pm – 9:30pm (choose one): General Session & Keynote Address, 9:15am – 11:30am Thriving on a Child Life Salary: Financial Planning for Life Lunch in Exhibit Hall, 11:30am – 1:30pm Personal Investment Management and Asset Allocation International Member Networking Meeting, 12:00pm – 1:30pm Walking the Tightrope of Success: Learning to Manage Stress Opening Reception, 6:00pm – 8:00pmSaturday, May 27 Sunday, May 28 Committee Meetings (Committee Members), 8:00am – 9:30am “Sunday Brunch” Networking Sessions, 9:45am – 11:15am Lunch in Exhibit Hall, 11:30am – 1:30pm Distinguished Service Award Presentation & Town Hall Session with Executive Board, 5:00pm – 6:00pm Closing General Session, 11:30am – 1:45pmDate Sent:Check / Trans #:Date Received:Personal Institution Check Credit CardAmount:1 of 2