Registration Form

Sara Schuh Child Abuse Conference

Interested participants may register on-line by credit card OR use the brochure form to register by credit card or check and submit the form by mail. Please use ONE registration form per person. Completed printed forms or online registrations with check payments due should be mailed with appropriate payment amount (checks made payable to the SCPSAC or MasterCard/VISA credit card account information listed below) to:
SCPSAC; 605 Baldwin Dr.; Sumter, SC 29150.

Federal Tax ID # 57-1024664.

You will receive confirmation of your registration. Questions?
For Registration questions please contact SCPSAC Treasurer Valerie Williams at vwilliams605@gmail.com.
For Content questions, please contact Anne Abel, MD at abela@musc.edu or (843)792-2618.

Registration Fees

Basic Registration Fee $ 10.00 (Everyone pays)
(includes registration, breakfast & lunch)
+

Medical/Nursing CME/CEU Fee $ 25.00

Mental Health/Social Work CEU Fee (FREE) No extra charge

Attorney/GAL/Legal CLE Fee (FREE) No extra charge

** Note there will be a MUSC Parking Cost for April 30, 2009 at MUSC. Conference participants should park in the MUSC Ashley-Rutledge Parking garage that can be entered/exited from Ashley or Rutledge Ave. MUSC maps and parking information are available at www.musc.edu .

REGISTRATION FORM

PLEASE FILL OUT ALL INFORMATION AND CLICK "SUBMIT"

REGISTRATION WILL NOT BE COMPLETE
WITHOUT FULL INFORMATION PROVIDED.

WE MUST HAVE A TELEPHONE NUMBER AND AN EMAIL ADDRESS FOR CONFIRMATION.

USE THE TAB KEY TO PROCEED TO THE NEXT FORM FIELD.
Important Note: Please use upper and lower case entries not all caps. Thank you.

LAST NAME:

FIRST NAME:

ORGANIZATION:

ADDRESS:

CITY: STATE: ZIP:

EMAIL ADDRESS:
* Necessary for email confirmation

PHONE: FAX:

_________________________________________________________________________

Track and Credit Selections

Please choose your track:

Will you be applying for CME/CEU/CLE credit? Yes No

_______________________________________________________________________

METHOD OF PAYMENT
The following are accepted methods of payment. Please select one.

Paying by Check or Purchase Order Check/PO #
Note: Make checks payable to SCPSAC

Credit Card payment (select one)

(PLEASE enter your card number WITH DASHES, i.e., 1234-1234-1234-1234)
Card Number Expiration (mm/year, 03/2010)

Security Code (on back of card, 3 digits)

Name on Card

Name of Authorized Signee

Total Amount to be paid by check or charged to credit card for this registration
$