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A Peer-CenteredMental Health Conferencefor Consumers, FamilyMembers, and CliniciansFEATURINGKeynote presentations, educationalworkshops, pre- and post-conferenceinstitutes, relaxation sessions, peerroundtables, support groups, comedynight, and much more!Full Conference Registrationas low as $95Register before April 15, 2011,and save up to 25%PEER CONNECTIONSDBSA 2011NATIONAL CONFERENCEHOUSTON, TX MAY 20-22, 2011Keynote SpeakersPatty DukeClarence JordanLaura BurkeSusan BlaunerDukeFriday, May 20 -Sunday, May 22, 2011Westin Galleria HoustonHouston, TexasBurkeJordanBlauner(800) 826-3632www.DBSAlliance.org/Conference2011

dbsa national conference registrationregistrant informatioN. Please print or type clearly. One registrant per form.Form may be photocopied if needed.• Denotes required fields by all participants.* Denotes required fields by DBSA chapter/support group participants.t Denotes required accessibility/accommodation needs. See important note below.• Name • Daytime Phone E-mail• Address • City • State • ZipSpecial Dietary RestrictionsEmergency ContactOrganizationt Special Accessibility/Accommodation NeedsEmergency Contact PhoneHow did you hear about the conference?*Name of DBSA chapter/support group *City of chapter/group *State of chapter/groupPlease circle the cost of each event you’re purchasing in eitherthe Early Bird, Advance, or Late & On-site column based on whether you are a DBSA Donor*, chapter/support group participant, or Non-Donor.eventEarly Bird(on/before April 15)Donor* or Non-DonorChapterAdvance(April 16 - May 13)Donor* or Non-DonorChapterLate & On-site(on/after May 14)Donor* or Non-DonorChapterConference n FULL Conference and Saturday ONLY Registrations Include Box Lunch on SaturdayFULL Conference n$95 $110 $110 $125 $125 $140(Sat. AM - Sun. noon)Saturday ONLY n $75 $85 $85 $95 $95 $105Sunday Morning ONLY $40 $45 $45 $50 $50 $55special events Proceeds from reception and lunch benefit Chapter Leadership Fund and DBSA ProgramsFriends Reception (Thu.) $40 $40 $60 $60 $80 $80Meet & Greet (Fri.) FREE FREE FREE FREE FREE FREEComedy Night (Sat. ) $5 $5 $10 $10 $15 $15President’s Lunch **(Sat.) $400 $400 $450 $450 $500 $500Pre-Conference Institutes ONLY available with purchase of full or single-day conference registrationLiving Well (Fri., 9 - 12) $30 $35 $35 $40 $40 $45Workplace (Fri., 9 - 12) $30 $35 $35 $40 $40 $45Staying Alive (Fri., 1:30 - 4:30) $30 $35 $35 $40 $40 $45*Donors are those who have given $50 or more to DBSA’s national office within the past 12 months.**FULL conference registration is included in the purchase of a President’s Lunch ticket.POST-Conference Institute: : Available with or without conference registrationMental HealthFirst Aid Training(Mon., May 23 - Tue., May 24)8:30 - 4:00 both daysWITH Conference Registration$125WITHOUT Conference Registration$150IMPORTANT NOTEIndividuals MUST indicate on this form any special accessibility or accommodation needs so thatDBSA can provide the appropriate resources. We request that individuals provide a minimum of onemonth’s notice (April 19, 2011) so that we can ensure that resources are available and that they can besecured at a reasonable rate.please considerDid you know that DBSA spends over $200/person for each FULL conference registration? If youhave the means to do so, please consider donating below to help offset the difference in actual costsand the registration fee. By doing so, you’re helping ensure that future educational programs areavailable to as many individuals as possible. Thank you!DONATION• Donors are those who have given $50 or more to DBSA’s national office within the past 12 months.• Non-donors will receive the donor rate if they contribute at least $50 at the time of registration.I’d like to give to DBSA.You may choose one of the following donor categories:Hope $50 - $149 Strength $150 - $299 Wellness $300 - $499Empowerment $500 - $1,499 Recovery $1,500 + Other amountPEER CONNECTIONSDBSA 2011NATIONAL CONFERENCEHOUSTON, TX MAY 20-22, 2011You may also register online atwww.DBSAlliance.org/Conference2011please return registrationform with payment to:DBSA730 N. Franklin Street, Suite 501Chicago, IL 60654Toll-Free: (800) 826-3632Fax: (312) 642-7243A confirmation letter will be sent uponreceipt of your registration form andpayment. Please allow three weeks foryour confirmation.Cancellations: Refunds (minus a $25cancellation fee) will only be given if youcancel more than three weeks beforethe conference. You may transfer yourregistration to another person. However,you must notify us in writing of anycancellation or transfer no later thanApril 30, 2011.Conference events are subject to additionsand changes. DBSA reserves the right tocancel this conference at any time. In theunlikely event that this occurs, registrationfees will be refunded in full.More Informationis available through our website,www.DBSAlliance.org/Conference2011• Speaker biographies• Session descriptions• Hotel and travel discountspayment methodCheck or money order is enclosedpayable to DBSA (in U.S. dollars)Charge my credit card.MasterCard VisaDiscoverAmExAccount Number CVC Code Exp. DateDONATION AMOUNT......................................................................................$__________CONFERENCE FEES........................................................................................$__________total amount enclosed...............................................(in U.S. dollars) $__________Name as it appears on card (Please Print)Signature (Required)