REGISTRATION
FORM
5th
Biennial
Adoption Conference
Title:
Identity
and the Adopted Teen: Surviving the Crucible of
Adolescence
Name__________________________________________
Address______________________________ City______ State
_____Sip__________
Phone_____________________ E-mail______________________
ATTENDEE
TYPE
1: First time attendee to St. John’s University Continuing
Professional Education
Offerings (i.e., Adoption conferences, workshops, etc.) Yes
( ) No ( )
If yes, what program(s)?______________________
When?_______________
2. Are you current student at SJU? Yes ( ) No ( ) ____ (if
other school, specify school):___________________
3. St. John’s University alumnus? Yes ( ) No ( ) Year of
graduation______
ATTENDEE
CATEGORY
( )
Professional (Specify_____________) ( ) Student (Specify
school:___________)
( ) General Public (Specify___________) ( ) Adopted person
( ) Parent (Circle One: Birth, Foster, adoptive, kinship,
Guardianship, Step) __Other:_____________
FEE
Single
Day(Friday or Saturday)
Before
September 10 After September 10
•
General
$100 $130
•
Student (with
valid ID)
$45 $60
•
Both Days
(Friday and Saturday)
•
General
$180 $230
•
Student (with
valid ID)
$75 $105
Total
Registration Fee: $_________
WORKSHOPS/PAPER
SESSIONS (To
make your selection please check our website
www.stjohns.edu/adoptioninitiative after
July 1, 2008 for the final listing of all the
workshops/papers)
BOX LUNCH
October 24: $ 10
Circle one type
of sandwich: Roast Turkey Chicken Salad Grilled Vegetables
Roast Beef
October 25: $ 10
Circle one type
of sandwich: Roast Beef Chicken Breast Roasted
Eggplant/Vegetables
DONATION
REQUESTED
In addition to
the registration fee I would like to make a tax-deductible
donation of $________ to support the adoption initiatives.
Donation will be ( ) in my name ( ) name of
_______________________. St. John’s University is a 501 (c)
(3) nonprofit organization. Your contribution is
tax-deductible to the extent allowed by law. Upon receipt
of the donation, you will be provided with a receipt with
St. John’s University tax ID number.
PAYMENT FOR CONTINUING EDUCATION
A separate
check is required for continuing education credit. Please
check the CE category requested, as follows:
( )For Psychologists
and General audience, write check
payable to St. John’s University
•
____$20 for one
day (October 24 or October 25)
•
____$35 for
both days (October 25 and October 25)
( )For Counselors,
write check payable to Montclair State University
•
____$20 for one
day (October 24 or October 25)
•
____$35 for
both days (October 25 and October 25)
(
)For Social
Workers, write check
payable to Rutgers University
•
____$20 for one
day (October 24 or October 25)
•
____$35 for
both days (October 25 and October 25)
(You
will be provided with a certificate after the completion of
the conference)
SATURDAY NIGHT AWARDS DINNER
We are honoring
two outstanding scholars and contributors to the field of
adoption: Dr. Joyce Maguire Pavao and Dr. Betty Jean
Lifton. Check below if you intend to attend.
(Price:
$____)
____Yes
(Separate check included) _____ No
PAYMENT METHOD
We accept
payment by check, money order or credit card. If paying by
credit card please include the information below. Please be
aware that we will charge your credit card the fee for CE.
For those paying by checks, please include a separate check
payable to the sponsor institution for CE credit category
requested.
AMOUNT
DUE AND PAYMENT
Registration
Fee: _____ Lunch Fee: ______Tax Deductible Donation: _____
CE Credits Fee: ______
Awards Dinner Fee: _________
Total
Amount Due: _________________
Credit Card
Information: ( ) AMEX ( ) Visa ( ) MasterCard
Card Number: _________________________ Code#: _______Exp.
Date: ___________________
Signature: _________________________________________
REFUND
POLICY
Refunds prior
to September 10, 2008 will be subject to $25 administrative
fee. No refunds granted after September 10, 2008.
MAIL
THE COMPLETED FORM WITH PAYMENT TO
St. John’s
University
Office of Postgraduate Professional Development Programs
Marillac Hall 402B
Queens, N.Y. 11362
OR
FAX IT TO
718-990-5485