October 16-18, 2014 at the University of Il-Chicago Conference Registration Form for Students and Professionals. Full 3 Day Conference Registration (This fee covers all 3 days of the Conference) Category Professional Cost Student (Valid Current School ID Required) Enter X for your selection $160.00 $90.00 Single Day(s) Conference Registration (For 1 or 2 day registrations) Category Professional Student (School ID Required) Cost Circle your selection $65.00 for each day $35.00 for each day 1 day ($65.00) or 2 day ($130.00) 1 day ($35.00) or 2 day ($70.00) For Single Day Registration (s) , circle the date(s) you plan on attending: Circle day (s) for your registration Thursday Friday Saturday Payment: Personal or Organizational check must be made be made payable to Latino Social Workers Organization, and mail payment to Latino Social Workers Organization (LSWO), Conference 2014, 1721 West 17th Street, Chicago, IL 60608. I will pay the following the following amount for the 2014 Conference: $____________(Based on fees above.) If paying by credit card, please complete the following: Credit Card Number Expiration Date and CVV Code Name on Card Expiration date:_______________CVV Code_______________ Billing Address of the card (The LSWO has PayPal available at the conference website, so either you pay online, or you can fax documents, and we will charge your credit card.) I give the LSWO permission to charge my credit card, please provide signature: Signature for Credit Card: _______________________________________________________ State and License Number Mailing Address: Name Address City, State/Zip Phone/Mobile Contact Email @ Home ( ) Cell ( ) Fax: ( ) The Latino Social Workers Organization (LSWO) will not share your registration information with any organization. For attendees who need continuing education units, your information will be shared with Jane Addams College of Social Work, who will be the provider of continuing education credits. Also, Jane Addams College of Social Work will charge a nominal fee of $5.00 for attendees who need continuing education units. Cancellation/Refund Policy: The Latino Social Workers Organization understands that paid registrants may need to seek a refund. Written requests for refunds must be sent to the LSWO by email to: [email protected]. Refunds will be issued no later than 45 days following receipt of your notice of cancellation and refunds will follow the schedule below: From August 31, 2014 to September 30, 2014: 50% Refund for paid registrants for the 2014 Conference. From October 1, 2014 to October 15, 2014: 25% Refund for paid registrants for the 2014 Conference. The Latino Social Workers Organization appreciates your attendance and support of the 2014 Conference. Please feel free to contact us through our communication gateways: Phone: (312) 212-3857 Fax: 1 (866) 488-7813 Email: [email protected] or [email protected] Conference website: www.lswo2014.org Organizational website: www.lswo.org Latino Social Workers Organization (LSWO) Conference Committee 2014: Adrian Delgado, LCSW Judith Rocha, LCSW Norma Haro, MSW Grecia Mendiola, MSW cand. Sandra Montes, LCSW, Type 73