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

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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
ANNUAL CONFERENCE REGISTRATION FORM – Part 2Registrant Name:__________________________________________________________CONFERENCE SESSION SELECTIONIncluded with basic registration fee. Please indicate which sessionsyou would like to attend; select only one session number perseminar/workshop period. To determine the session numbers, referto the conference program, or the CLC Web site atwww.childlife.org. Admission is on a first-come-first-served basis.Name badges will be required for entrance to all sessions and tothe exhibit hall.Friday, May 26, 2006Professional Development Seminars, 1:45pm – 3:45pmSelect one from session #s 1 – 6: ___________Professional Development Workshops, 4:00pm – 5:30pmSelect one from session #s 7 – 14: __________Saturday, May 27, 2006Professional Development Workshops, 9:45am – 11:15amSelect one from session #s 15 – 22: _________Professional Development Workshops, 1:45pm – 3:15pmSelect one from session #s 23 – 31: _________Professional Development Workshops, 3:30pm – 5:00pmSelect one from session #s 32 – 39: _________Sunday, May 28, 2006Professional Development Workshops, 8:00am – 9:30amSelect one from session #s 40 – 46: _________Sunday Brunch Networking Sessions, 9:45am – 11:15amSelect one from session letters A – Z: ________ I’d like to volunteer as a room monitor for one of theseminars/workshops I have selected above, #__________.REGISTRATION FEES (all in US Funds):Receivedby April 3Receivedby April 28ReceivedOn-SiteProfessionals:CLC Member $235.00 $285.00 $335.00Non-Member* $350.00 $395.00 $450.00Full-Time Students:CLC Member $175.00 $225.00 $275.00Non-Member* $235.00 $275.00 $335.00Retirees (Age 65+):CLC Member $175.00 $225.00 $275.00Exhibit Hall Only (for guests):Friday:$50.00 (includes lunch and reception)Saturday:$20.00 (includes lunch)*To become a CLC member, please fill out the enclosedmembership application and return it with your registration.2 of 2REGISTRATION FEE CALCULATIONBasic Registration Fee (refer to chart) $Applicable Discounts: ______________ -$Exhibit Hall Guests (Friday)Number of guests ______@ $50 = $Exhibit Hall Guests (Saturday)Number of guests ______@ $20 = $Basic Registration Fee Subtotal $Full-Day Supervision Intensive, Thursday$100 Professionals Only $Half-Day Intensives, Thursday (select one): A B C$50 Professionals; $30 Students $Networking Event at theDallas World Aquarium, Saturday_______ tickets @ $45_______student/child tickets @ $35 = $Additional Events Subtotal $HOSPITAL TOURS: $15 per ticketLimited availability – first-come-first-served!Children’s Medical Center of DallasThursday, May 25, 2:00pm – 5:00pmSunday, May 28, 3:30pm – 6:00pm $Cook Children’s Medical Center DallasSunday, May 28, 2:30pm – 6:00pm $Medical City Children’s HospitalThursday, May 25, 2:00pm – 5:00pmSunday, May 28, 3:30pm – 6:00pm $Texas Scottish Rite Hospital for ChildrenThursday, May 25, 2:00pm – 5:00pm $Hospital Tours Subtotal $TOTAL AMOUNT DUE $PAYMENTPayment must accompany registration form. For information onrefunds/cancellations, please review the cancellation policy on page1 of this insert. Please check one: A Check or Money Order, payable to Child Life Council, isenclosed in the amount of $____________(US Funds Only). Please charge $_____________ to the following credit card.*Name on Card:Visa/MasterCard Number:Cardholder Signature:Expiration Date:X____________________________________________*Note: All non-US participants will be charged using the current USdollar exchange rate at the time the credit card is processed.
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Let YourStar Shine Bright... Let Your Star Shine ... - Child Life Council

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