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Participant information

*First Name:

*Last Name:

*University/Affiliation:

*Department:

*Address1:

Address2:

City:

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Country:

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*Email:

Phone:

Arrival Date/Time:

Departure Date/Time:

Staying at the Hyatt Regency Hotel?

Event	Before 12/27/2012	On or After 12/27/2012
CUDCP	$300	$350
CCHPTP	$200	$225

CUDCP Conference Selections: Indicate your preferences below:

Thursday, January 17, 2013

9:00 AM-5:00 PM

CoA Site Visitor Training workshop (breakfast and lunch provided to pre-registered attendees)

12:00 PM-5:30 PM

(Evening workshop) CoA Self-Study Preparation workshop

Friday, January 18, 2013

7:00 PM-9:00 PM

New DCT workshop

Saturday, January 19, 2013

5:00 PM-6:45 PM

Diversifying Clinical Psychology Reception and Poster Session

NOTE: If you selected the CoA session, your selections will be automatically emailed to Ashi Kapur @ APA when you click on the payment options below

CCHPTP Conference

Sunday, January 20, 2013 - All day meetings (breakfast and lunch provided)
Monday, January 21, 2013 - Meetings until noon (breakfast provided)

Yes, I plan to attend and have included the registration fee with my payment

If you are bringing a guest who wants to attend any of the functions associated with the meeting, please contact Steve Miller by email at lsmiller@uga.edu to make the necessary arrangements.

Total amount payable :

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