2011 Southern California Bioenergetic Conference
March 25-28, 2011

Fields marked with an asterisk (*) are required fields.

* Name: (as you want to appear on your badge)

* Address

* City

* State/Province * Zip Code * Country

* Phone Number

* E-mail

Registration Fee
Early registration fee (must be received by 11-14-2010) Save $100 register before November 14!
IIBA Members $365 Non-IIBA $390
Registration fee (after 11-14-2010): IIBA Members $465 Non-IIBA $490

Accommodation Fee
Condolet (double) - $540 Cedar lodge (single) - $630
Accommodation fee $

Guest Fee (conference non-participant) - $130 (per night)
Guest fee $

* Lodging Dates

Guest Name

MFT License #

LCSW License #

Number of Licenses

Total for Licenses ($15 per license) $

* Discount $100 if postmarked or submitted via Pay Pal by 11/14/10 $ (less)

* Total Conference Cost $

* Conference Deposit: (accommodation fee)

* My Balance Due by February 1, 2011

* Method of Payment
Check (Make check payable to SCBC)
Paypal

* Payment amount option:
Payment in full enclosed
Payment of deposit (accommodation fee: $540 double or $630 single) balance due on 2/1/11

* Process Group Preference:
Non-Therapist Group
Graduate/CBT Group
Bioenergetic Student
Therapist Group (holds current license to practice psychotherapy)
Bioenergetic Faculty Group

* Personal Information: all conference attendees

*IIBA Member Yes No
IIBA Member (Society/Institute)

*Completed Bio Curriculum Yes No

*Current Bioenergetic Student Yes No         (Number of years as a student) 1 years 2 years 3 year 4 years 5 years More than 5 years

Institute

*Current Therapist (to be used for grouping purposes only)

*I have had Bioenergetic Therapy Yes No

*This is my first Conference Yes No

If you are staying in a Condolet, you may indicate one roommate (please confirm with them)

Any special dietary or rooming needs?

Refund Policy: There is a $50 processing fee for all refunds.
After November 14, 2010 and before February 1, 2011: you will be responsible for 1 night's lodging plus $50
After February 1, 2011: you will be responsible for 3 night's lodging plus $50 processing fee.