Pacifica Graduate Institute | Public Programs & Conferences

When History Wakes Registration Form

Complete this registration, then print it out and return it to Pacifica Graduate Institute with your payment.
(*indicates required field)



First Name:*
Last Name :*
Email:*
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City:*
State/Province: *
Zip/Post Code:*
Country:*
Home Phone:*
Work Phone:
Fax:
How did you hear about Pacifica?*

Conference Fee:
General Admission Fee: $275
Special Admission Fee: $225
(check one of the catergories below)
Full Time Student
Pacifica Alumni
Senior (65 years & older)
Joseph Campbell & Marija Gimbuta Library Member

Please select one concurrent presentation for each of the following sessions:
Saturday: 1:15–3:15 PM	Saturday: 3:35–4:15 PM
Brent Blair	Ismana Carney
Constance Buck	Craig Chalquist
Canto	Melinda Harthcock
Tayria Ward	Michael Martella
	Ruth Meyer
Saturday: 4:30–5:10 PM	I Am Planning To Attend:
Susan Laskowski	Friday Dinner
Anthony Palombit	Saturday Breakfast
Patsy Shealy	Saturday Lunch
Sylvia Villareal	Saturday Dinner
	Sunday Breakfast

Meals: Please include me in the following meals
Full Meal Plan - $75
Lunch and Dinners Only - $55

Dietary Requirements:
Vegetarian Vegan Other (explain)

Accommodations at La Casa de Maria:
Please reserve a room for me at La Casa de Maria—$70 per person per night
Friday, October 15
Saturday, October 16
Other
Single Double I will be rooming with

Continuing Education Credit:
($15 each certificate)
MFT LCSW RN
Certified Counselor Psychologist

I would like to become a member of the Joseph Campbell & Marija Gimbuta Library
Membership Fee: $50

TOTAL ENCLOSED:

Please indicate method of payment:
Check Enclosed:	Payable to Pacifica Graduate Institute
Please Charge:	Mastercard Visa Discover
Account Number:
Expiration Date:
Cardholder Name:
Signature:	_________________________________________


Submit this completed Registration by mail to: Pacifica Graduate Institute Public Programs 249 Lambert Road, Carpinteria, CA 93013 Or by fax to: 805-565-5796
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