29th Annual ARC Summer Intensives, Registration

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June 21-23, 2015 in Provincetown, MA

Please submit a separate registration form for each attendee.

Full Name *

Street Address *

Apartment or Unit #

City *

State *

Zipcode *

Phone number (primary) *

Phone number (secondary)

Email address *

Have you attended the ARC Summer Intensives in the past? *

If yes, please note the reduced "repeat" fees listed below

Yes

Type of Registration *

Some partial scholarships available - contact eakinnect@gmail.com for information

All Three Full Days: $425 ($295 repeat)

Sunday Full Day Only: $150 ($135 repeat)

Monday Full Day Only: $225 ($175 repeat)

Tuesday Full Day Only: $225 ($175 repeat)

Required

Are you requesting CEUs? ($50 per day) *

CEUs available for social workers and LMFTs for Monday and Tuesday only

Yes

If requesting CEUs, what is your license type?

(LCSW/LICSW, LMHC, or LMFT)

If requesting CEUs, what is your license number?

If requesting CEUs, what is your state of licensure?

Select any and all that apply

I am an adopted person

I am a birthparent

I am an adoptive parent

I am a foster parent

I am a parent by alternative reproductive technology

I am a social worker

I am a health care provider

I am a psychologist

I am a lawyer

I am an educator

Other:

Total payment amount *

(session fees plus CEUs, if requested)

Form of payment *

A representative of AACT/PCC will call me to take credit card information over the phone.

Submit

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