- Opening Pandora\'s Box Registration Form -
Opening Pandora\'s Box
Thursday, June 11, 2009
Full Name:
*
Degree:
*
Organization:
*
Address:
*
City:
*
State:
*
Zip Code:
*
Email:
*
Day Phone:
Work Phone:
*
Discipline:
*
Years in Field:
*
Program Options - Check All That Apply:
Please reserve a box lunch for me
I require a vegetarian lunch or have other dietary restrictions
I wish to enroll in the child Sexual Abuse Treatment Certificate Program
I will require Continuing Education Credits for American Psychological Association
I will require Continuing Education Credits for Pennsylvania Social Work
I will require Continuing Education Credits for Act 48
(Choose at least 1 option)
Fees - Check All That Apply:
Regular Conference Fee $150
Group of 3 or more Fee $100
Student Rate $60
10% Alumni Discount, Regular Conference $135
10% Alumni Group Discount, 3 or more staff $90
Fundraising Lunch $25
(Choose at least 1 option)
If Widener Alumni, year of graduation:
If Widener Alumni, degree:
Form of Payment:
Will mail check or money order payable to Widener University, University College, One University Place, Chester, PA 19013
VISA
MasterCard
(Choose at least 1 option)
Account Number:
Expiration:
Security code - 3 digit csv:
Name as appears on card:
Total Fees:
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