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Registration Form

2005 ICP Convention July 16-20, 2005, FOZ DE IGUACU, Brazil

“Promoting Mental Health Across Cultures and Nations”

PLEASE SUBMIT REGISTRATION VIA THE WEBPAGE!! IF THIS IS IMPOSSIBLE

Mail to:            Dr. Sherri McCarthy & Dr. Claudio Hutz

                                    Vicente da Fontoura 2570

                        90640-002 PORTO ALEGRE, RS, BRAZIL

               _____Dr.            _____Prof.                _____Ms.               _____Mr.          _____Mrs.

Name:                                            Department/Organization:

Preferred address for correspondence:

Street:                                            City: 

State/Province/Region:                  Zip or Post Code:                  Country:

Telephone (include country code):                                            Fax  (if available):  

Email:

Special dietary requirements if any (Please specify) :

Please detail any disability requirements (i.e. preference for ground floor room, etc):

ACCOMPANYING PERSON REGISTRATION (if needed)

Preferred Name on Badge:

Special dietary requirements, if any  (Please specify):

Registration Fees:

                                                                    Early Registration                                 After April15, 2005 or Onsite

ICP regular member                            US $200____                                      US$225____

           ICP member from Category C:

            Countries (non-subsidized)                   US $100____                                      US $125____

Students                                              US $ 75____                                       US $100____

Accompanying person                          US $150____                                      US $175____

Non-member                                        US $220____                                      US $240____

Non-member from Category C

            Countries (non-subsidized)                    US $110____                                      US $130____

            Brazilian and Russian Delegates             US $50  ____                                      US $60  ____

 

                                                                                    Total        US$_________

Ř      Registration fee includes admission to the opening reception and all sessions EXCEPT Continuing Education Workshops.

Ř      Hotel is extra and the rates will include breakfast. Hotels, meals, banquets t-shirts and recreational activities must be registered for separately (see travel information link ).

ICP members may register for the 2nd International Conference on Psychology Education at reduced rates. Please check here if you also plan to attend this conference (July 12 – 15).

Please indicate payment method:

             Credit Card (VISA CARDS ONLY!! Include details below)

             Cash or check (Brazilian Reis or US Dollars only. MUST BE PAID ONSITE AT ONSITE RATE)

Visa Credit Card Details-- Cardholder Name:

Postal Address:                                                                     Telephone Number:

Card Number:                 Cardholder Name (as on card):     Card Expiry Date (MM/YY):