Regional Workshop Registration

Select Workshop:*

First Name:*

Middle Initial:

Last Name:*

Preferred Name (for name badge):

Degree:

License #:

Address 1:*

Address 2:

City:

State:*

Country:*

Zip Code:*

E-mail:*

Office Phone:

Home Phone:

I would like to receive all correspondence for this meeting electronically.

MEMBERSHIP

I am a member of:

ASCH
SCEH
Non-Member
Component Section

ASCH Membership Number (ID#):

For Students/Residents:

Please provide information on your graduate program, indicate a masters or doctoral level, and provide written confirmation from your school/program of your enrollment.

FEES

Workshop Fee:*

Workshop Level:*

I would like to request the Virginia Hypnosis Fund Grant. I will mail the required written request.

Number of Copies:

"Hypnotic Induction and Suggestion" - $20 each

Do you wish to receive a CE Certificate/Letter of Attendance:

I wish to receive my CE Certificate/Letter of Attendance
I DO NOT want to receive CE Certificate/Letter of Attendance. Please remove $25 from my registration.

Letter of Attendance:

Printed Handout Option:*

I wish to print my own handouts for this workshop. Please remove the $37 handout fee already included in the registration fee.
I DO NOT wish to print out my own handouts for this workshop.

PAYMENT

Payment Information:

Credit Card
Check

Grand Total:

If there is no dollar amount re-click the button you selected for "Printed Handout Option" above and it will calculate the grand total.

ADA STATEMENT

ADA Statement: In compliance with the Americans with Disabilities Act (ADA), please check this box if you require assistance because of a disability to make this program accessible to you. Someone from the ASCH Office will contact you.

I require assistance

CANCELLATION POLICY

Cancellations postmarked/faxed between 2 and 4 weeks prior to the first day of the meeting will receive a refund of the amount paid less a $50 administrative charge. No refunds within two weeks of the first day of the meeting. Exceptions will only be granted due to death of the participant or an immediate family member, severe illness/injury of the participant or an immediate family member, or the inability of the participant to travel due to legal or government restrictions/obligations, and require written notification and appropriate documentation. Registration fees are not transferable to another workshop.

Scope of Practice - Agreement

By submitting this registration I agree that I understand that the rules and statues of the states vary in terms of the use of clinical hypnosis and that the individuals accept responsibility for the care of their clients or patients consistent with the individuals' discipline and licensure and that they should seek out consultation and/or supervision when in doubt regarding their clinical practices or when questioned by others about their clinical practice and that I will only use hypnosis within the scope of my practice

SUBMISSION NOTICE

Once you click the "Submit Registration" button, your credit card will be charged and you should be re-directed to a "Thank You" page. If you are re-directed to a page that says "CRITICAL ERROR" please note that your registration has been submitted and your credit card has been charged. If you did not receive a confirmation email please call us at (630) 980-4740 to verify your registration status before submitting again.