NAME (INCLUDING DEGREES)

ADDRESS

CITY

STATE

ZIP

COUNTRY

FIRST NAME FOR BADGE   

PHONE

Retype E-MAIL

PROFESSION    
(eg. Social Worker, Psychologist)

In case of emergency notify:

(ADA)- Please notify if you have special needs

Check all that apply

Presenter
Paid deposit Deposit Not paid

First Time ASGPP Conference Attendee

Retiree (no longer employed, doing training or in private practice)

Student (matriculated in an accredited college/university program)

Member Non-Member New Member

Psychodrama Training Group (See Group Rates below for discount qualifications)
   Specify group

NEW MEMBER INCENTIVE

Become a member today and receive a special conference
promotion discount of 50% on your dues and enjoy member
rates to attend the conference. New member rates are $60
(regular) and $30 (student). This offer is limited to those
who have never been an ASGPP member.
Students must submit Student picture ID.

REGISTRATION FEES
All fees are given in $US

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Member
Student
Member
Retiree
Non-Mem
Student
Non-Mem
Retiree
Member
Non-Mem

Full Conference
(Friday, Saturday and Sunday)

$100
$310
$260
$100
$310
$260
$115
$325
$275
$115
$325
$275
$500
$625
$

1 Day Conference Pkg. Fri. Sat. Sun.

$130 $130 $135 $135 $175 $210

$

Full day Conference Institute (Thurs)

$130 $130 $135 $135 $175 $210 $

Half day Conference Institute (Thurs)

$65 $65 $70 $70 $90 $110 $

ADDITIONAL EVENTS

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Friday Awards Dessert Reception (included in Full Conference package)

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Number of tickets @$20

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Boxed lunch - click on days Thu. Fri. Sat. Sun. (menu will be sent)

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Number of tickets @$30

Here is and additional tax-deductible contribution toward this year's Scholarship Fund

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2017 Membership Dues
All members add ($10) if you are from a country other than the US, Mexico or Canada

Regular $120 Retired/Student $60 (Must submit picture ID)

CE Forms- we will provide one form that can be used for all licensures as verificaiton

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Credit card fee

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TOTAL ($US)

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Please Review Conference Information and Refund Policy
I understand and accept the refund policy (your registration cannot be processed if you have not acknowledged the cancellation policy).

Please make checks payable to ASGPP, and send mailed registration forms to:
ASGPP,301 N. Harrison Street, Suite 508, Princeton, NJ 08540

TO USE YOUR CREDIT CARD
Please note that we will calculate a 2.2% +.30 fee for each credit card transaction. To avoid this fee, please follow the instructions below for paying by check.
TO PAY BY CHECK/MAIL
To print, fill out the form completely but instead of clicking the Submit button use File, Print or Cmd Print or Ctr Print from your browser and then mail form and check to the office.

DO NOT E-MAIL credit card information.

GROUP RATES: PSYCHODRAMA TRAINEE RATES: ASGPP is offering a reduced rate to psychodrama training institute trainees - $400 per person. All registrants taking advantage of the trainee rate must be members of the ASGPP. Participation in a training group will be verified in order for the discounted rate to apply.
  ASGPP is offering a special group rate for the Full 3 day Conference to college/university students and agency employees. Six (6) or more students must register together at the Group Rate of $255/per person. *Students must be matriculating in an accredited college/university and carrying a minimum load of 9 credits and/or pursuing a full-time residency or internship. All student registrations must be sent in the same envelope and include photocopies of college/university picture identification. We are also offering a group rate for three (3) or more attendees from a mental health or medical agency or hospital at the rate of $440 per person. Registrations must be sent together with a letter from the agency/hospital administration, listing the attendees/employees.
Please note: Anyone paying a “Group Rate” is considered a “Full Conference Registrant”.

IMPORTANT:
Please sign up for workshops on the following page.
Your registration cannot be processed if you have not signed up for the workshops you wish to attend.
Please scroll to the bottom and hit Submit.
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2017workshopHeader

Last Name

Please list your top three choices in order of preference for each workshop time frame. Space is extremely limited this year. If you do not list three choices, you may not get a workshop in that time slot. The numbers in parentheses indicate the workshops that are available during each time slot. Choose carefully .

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1ST CHOICE 2nd CHOICE 3rd CHOICE

Thursday May 4, 2017 - Pre-Conference

9:30 am - 5:30 pm *Full Day Training Institutes dots
(#1-6)

9:30 pm - 1:00 pm *Morning Training Institutesdots

(#7-10)

2:00 pm - 5:30 pm *Afternoon Training Institutesdots

(#11-14)

Friday May 5, 2017

10:00 am - 1:00 pm ALL Morning Workshops will be sociometrically selected ONSITE ONLY - at 9:00 am SHARP immediately following Plenary

3:00 pm - 6:00 pm Afternoon Workshops dots

(#26-36)

Saturday May 6, 2017

10:00 am - 1:00 pm Morning Workshops dots

(#37-47)

1:30 pm - 3:00 pm 90-Minute Workshops dots

(#48-58)

3:30 pm - 6:30 pm Afternoon Workshops dots

(#59-69)

Sunday May 7, 2017
9:30 am - 12:30 pm Morning Workshops dots
(#70-80)

1:00 pm - 2:30 pm 90-Minute Workshops dots
(#81-90)

3:00 pm - 6:00 pm Afternoon Workshops dots
*Additional Registration Fee Required
(#91-101)

How did you hear about the conference? Mailer Online Trainer/Teacher Ad in publication Colleague/Friend
Other, please specify

SESSION ASSISTANTS & VOLUNTEERS NEEDED!

VOLUNTEER SERVICE is a vital part of the ASGPP community and a successful conference program. We have four areas of volunteering: General Volunteer, Session Assistants, Onsite Processing Team Members and Silent Auction/Treasure Chests assistants. You can contact the coordinator of these areas to find out more about them or ask questions. Please indicate which area of volunteering you are interested in. The Coordinator of that area will contact you. We hope you will offer your services both on site and prior to the conference.

Yes, I am interested in being a General Volunteer. (Coordinator: Debbie Ayers, 609-737-8500, debbie@asgpp.org)

Yes, I am interested in being a Session Assistant. (Coordinator: Debbie Ayers, 609-737-8500, debbie@asgpp.org)

Yes, I am interested in being a Onsite Processing Team Member. (Coordinator: Jodi DeSciscio, 813-817-2909 ricodi@verizon.net)

Yes, I am interested in helping with the Silent Auction/Treasure Chests. (Coordinator: Julie Wells, 727-688-5800, cuerco@aol.com)

Please check the days you are available: Thursday Friday Saturday Sunday

NAME:

___________________________

PHONE (day):

________________________

E-MAIL:

__________________

PHONE (evening)
if different