REGISTRATION FORM

DIRECTIONS:  This is not an interactive form.  Select this page and copy as a new Word doc.  Once it is a Word document, fill in the enrollment information for your files, then paste and email to:  FreeMinds.edu@gmail.com. Your email should be secured but if in doubt, you may print and fax it to  510 523 5175, or print for mailing to: FREE MINDS 2011, c/o Fred Stitt, Director, Box 2590, Alameda, CA 94501.

Date of registration:

Register me in The Atlas Society / Free Minds 2011, Summer Seminar

Name(s):

Institution, organization, or school affiliation (optional):

Mailing address:

Email address:                                                                                    Phone:

__ Full conference registration fee(s):  __ $800 per person, single enrollment. 

__ $600 per person for double full conference enrollment.  __ $450 per person for additional full conference enrollments.

__ Part One only,  $450.   __ Part Two only, $450.   __ $350 per person for additional Part One or Part Two enrollment(s).

__ Single day(s) enrollment, $150 per day (specify day or days) __________________________________

Student registration fees: ____ student(s) at $150 per student.  Free enrollment and stipends for student conference assistants.  Contact freeminds.edu@gmail.com for information.  Contact wthomas@atlassociety.org.to inquire about scholarship options.

Total registration fee(s):  $ _________

__ I am paying by Check or Money Order (payable to Free Minds).  

__ I am paying by Visa, MasterCard, or Amex:

Card Number:                                                                            Card expiration date:

Cardholder's name:

***Note:  Credit card statement will show paid to “SFIA/GUIDELINES”***

I understand full refund will be provided if I have to cancel for any reason up to June 30, 2011.  After June 30, there'll be a $20 cancel charge. 

PARTICIPANT DIRECTORY OPTION

If you would like to be included in the Participant Directory, please add:

Your Job Role/Profession:

Interests/Hobbies/Talents:

Web site (optional):                                                Email or FaceBook contact information (optional):

SCHOLARSHIP SPONSOR OPTION  (Any amount is welcome.)

I would like to donate to the Student Scholarship Fund.

Amount:  $ _________     Include your name on the Scholarship Sponsor Roll?  ___ Yes   ___ No