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| First
Name: |
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| Last
Name : |
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| Address: |
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| City: |
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| State/Province:
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Zip/Post
Code: |
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| Country: |
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| Home
Phone: |
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| Work
Phone: |
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| Fax: |
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| Email: |
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| How
did you hear about Pacifica? |
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Seminar Fee:
(Fees include Friday dinner; Saturday breakfast, lunch, and dinner; Sunday breakfast and lunch)
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| $350 General Admission Fee |
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$300 Special Admission Fee
(check one) |
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| Full time Student |
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| Pacifica Alumni |
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| Senior( 65 years & Older) |
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| $275 Active Pacifica Student Fee |
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| Accommodations at Pacifica's Ladera Campus are SOLD OUT: |
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Please reserve a room for me. |
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Thursday, June 28
Friday, June 29
Saturday, June 30
Sunday, July 1 |
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$75
per night, single occupancy
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$110
per night, couple occupancy
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$120 per night, double occupancy |
| Add 10% Occupancy Tax on accommodations |
| I
will be rooming with |
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| Meals I plan to attend: |
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Thursday Breakfast (optional $10)
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Thursday Lunch(optional $15)
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Thursday Dinner (optional $18.50) |
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Friday Breakfast (optional $10) |
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Friday Lunch (optional $15)
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Friday Dinner (included) |
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Saturday Breakfast (included) |
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Saturday Lunch (included) |
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Saturday Dinner (included) |
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Sunday Breakfast (included) |
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Sunday Lunch (included)
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| Dietary Requirements: |
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Vegetarian
Vegan
Other (explain)
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| Continuing Education Credit:
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| ($15 per certificate)
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Psychologist
MFT
LCSW
RN
Certified Counselor |
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| TOTAL
ENCLOSED: |
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| Please
indicate method of payment: |
| Check
Enclosed: |
Payable to Pacifica Graduate Institute |
| Please
Charge: |
Mastercard
Visa
Discover |
| Account
Number: |
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| Pin Number: |
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| Expiration
Date: |
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| Cardholder
Name: |
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| Submit
this completed Registration online, or if you would
prefer print it our and mail or fax it to us:
Pacifica Graduate Institute
Public Programs
249 Lambert Road, Carpinteria, CA 93013
Fax:
805-565-5796 |
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