Registration Form

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

“Promoting Mental Health Across Cultures and Nations”
 

You May Submit PART I: REGISTRATION INFORMATION ONLY via the webpage
 
OR COPY and Mail to:           
Dr. Sherri McCarthy & Dr. Claudio Hutz
 90640-002 PORTO ALEGRE, RS, BRAZIL
                      Vicente da Fontoura 2570
                   

 

PART I: Registration Information

Please check one:

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 indicate 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 (please check appropriate boxes):    
  Early Registration (before April 15, 2005) After April 15, 2005 and 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 Persons 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  (Total of Above Fees)
   

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).
 
PART II: Payment Method (Must be mailed to address at top of form)
 
TOTAL FEES:  US $  _________________________
 
Please check 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 (please print):
Cardholder Name:   _______________________________________________________
Postal Address:       _______________________________________________
____________________________________________________________________
 
Telephone Number:  ______________________________________
 
Card Number:          _________________________________________________________
Cardholder Name (as on card):_______________________________Card Expiry Date (MM/YY): _______________
 

    Click "Submit" bar only ONCE and wait for confirmation page.