2015 CCNY REGISTRATION FORM - Counseling Center
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 [email protected]. (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
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