CHICAGO OPEN HOUSE FOR CLIENT-CENTERED THERAPY
Registration Form
Dates: Friday Nov. 6th 1:00 PM - Sunday Nov. 8th 12:00 PM
Location: The New Center Chicago, Illinois
Accommodations: Not included: information available upon request
Meals: All Included
Registration Fee
Regular registration before October 15th: $100.00
Late registration on or after October 15th: $150.00
Student Rate: $50.00
Scholarships Requests: Direct requests to Brian Burgess at psychbrian@thenewcenterchicago.com
Make Checks Payable to: The New Center / Send Form & Payment to:
Chicago Open House Registration
The New Center
3166 N Lincoln Ave Suite 325
Chicago, IL 60657
Name, Address, Phone, e-mail: _____________________________________________
________________________________________________________________________
____________________________________________________________________
SHIRT SIZE : _ SM _ MED _ LG _ XL _ XXL
(standard men's sizes)
Registration total: $________
Scholarship fund contribution: $________
TOTAL (enclose payment): $__________
(Note. Full refund available until October 31st, 2009)
Circle One: Visa MC AMEX DISC
CREDIT CARD NUMBER: _____________________________________
EXP DATE: ________________
Authorized Signature: _______________________________________________
Or Call to use credit card by phone: 773-405-3541
FORM CAN BE FAXED TO 773-404-8449
www.thenewcenterchicago.com
ONE FORM FOR EACH REGISTRANT PLEASE