2002 CONFERENCE REGISTRATION FORM

CONFERENCE REGISTRATION FORM

25th Annual International Conference on The Psychology of The Self
A SELF PSYCHOLOGICAL APPROACH TO GENDER AND SEXUALITY

Make checks payable to Self Psychology Fund. Full payment must accompany registration form. All fees must be paid in U.S. FUNDS DRAWN AGAINST A U.S. BANK. VISA and MasterCard also will be accepted. Fees listed are in U.S. dollars. Please use one form per registration. Form may be photocopied.

(Please print or type)

Last Name ____________________________________________________

Degree(s) __________________________ (to be printed on your name tag)

First Name ________________________________________________

Middle Initial _________________________

Address______________________________________________________________

City ______________________________ State _____

Postal Code ______________Country ____________________

Phone Number (_____) _______________________________

Fax Number (_____)__________________________________

E-Mail
Address _________________________________________________________

Profession ___________________________

State/Professional License No. _______________________________
(for Continuing Education Certificate)

Mailing Label Code__________________________
(To help us minimize multiple mailings, please list the number or code found on the brochure mailing label even if it was not addressed to you.)

OPTIONAL PRE-CONFERENCE WORKSHOP FEES

Postmarked By Sept. 26	Postmarked After Sept. 26
$ 45	$ 60

Optional Pre-Conference Workshops: (Select One)

A. Intersubjective Systems Theory

B. Art, Creativity and Self Psychology

C. Self and Orientation: When Orientations Differ

F. The Infancy of the Father-Mother-Child Triangle: A Developmental Systems View - Part I

OPTIONAL PRE-CONFERENCE COURSE REGISTRATION FEES

Postmarked
By Sept. 26 Postmarked
After Sept. 26

If taken with Main Conference $135 $160

Student*, if taken with Main Conference $ 70 $ 80

Pre-Conference Only $160 $185

Pre-Conference Only - Student $ 90 $100

Pre-Conference Courses (Select one):

1. Introductory Course

2. Advanced Course d

3. Couples Therapy Course

4. Group Therapy Course

PRE-CONFERENCE ADVANCED COURSE IN SELF PSYCHOLOGY

If you are registering for the Pre-Conference Advanced Course (Clinical Case Consultation Track), please indicate your choices for the Master Classes (small supervisory groups) in order of preference from 1-10. YOU MUST ATTEND THE GROUP TO WHICH YOU ARE ASSIGNED. Assignments will be made strictly on a first-come, first-served basis.

_____William J. Coburn, PhD, _____Wolfgang E. Milch, MD
Jeffrey J. Mermelstein, PhD

_____James M. Fisch, MD _____Andrew P. Morrison, MD

_____Paula B. Fuqua, MD _____Carol A. Munschauer, PhD

_____Jill R. Gardner, PhD _____Donna M. Orange, PhD, PsyD
Salee A. Jenkins, PhD

_____Andrea Harms, PhD, PsyD _____Tessa M. Philips, MA
Franz Herberth, MD

_____Jane C. Jordan, LCSW _____Maxwell S. Sucharov, MD

MAIN CONFERENCE REGISTRATION FEES

Postmarked
By Sept. 26 Postmarked
After Sept. 26

Professional $330 $360

Student* $200 $220

*Student registration MUST be accompanied by a letter from the Training Director verifying full-time status, photocopies of student ID will not be accepted.

Because meeting room capacities are limited by local fire laws, maximum capacities will be strictly adhered to for the concurrent sessions. We regret that we are unable to make exceptions. To avoid disappointment, we urge you to register early to be assured of attending your preferred sessions.

ORIGINAL PAPERS AND WORKSHOPS

SESSION A: Saturday Afternoon 2:15 - 3:45 PM

1st Choice No._____ 2nd Choice No._____ 3rd Choice No._____ 4th Choice No._____

SESSION B: Saturday Afternoon 4:15 - 5:45 PM

1st Choice No._____ 2nd Choice No._____ 3rd Choice No._____ 4th Choice No._____

SESSION C: Sunday Morning 8:30 -10:00 AM

1st Choice No._____ 2nd Choice No._____ 3rd Choice No._____ 4th Choice No._____

OPTIONAL SATURDAY LUNCHEON FOR CONFERENCE PARTICIPANTS

An optional luncheon will be held on Saturday beginning at 12:15 PM. The fee for the lunch and continuing education credit will be $40 U.S. in advance, $45 U.S. at the conference (based on space availability).

OPTIONAL SATURDAY EVENING CONFERENCE RECEPTION

A light Dinner Buffet followed by music and dancing. The fee for conference registrants and guests is $40 U.S./each in advance, $45 U.S./each at the conference.

GUEST MEAL TICKETS AND TRANSLATED PAPER (ITALIAN ONLY)

Guest tickets may be purchased for the Saturday Luncheon, the Saturday Evening Reception and for the Continental Breakfasts and Reception combined.

In Advance At the Conference

Registrant Luncheon Ticket $40 $45

Registrant Reception Ticket $40 $45

Guest Reception Ticket $40 $45

Guest Breakfasts & Reception Tickets $65 $70

Guest Luncheon Ticket $40 $45

TRANSLATED PANEL PAPERS (Italian only) $25/set

Guest's Name: _______________________________________________________

Will you need any special assistance at the conference? Please list your needs:

_______________________________________________________________

Fee Totals:

Optional Pre-Conference Workshop Fee $_________

Optional Pre-Conference Course Fee $_________

Main Conference Fee $_________

Optional Luncheon for Registrants $_________

Optional Reception for Registrants $_________

Optional Guest Tickets $_________

Translated Panel Papers $_________

TOTAL AMOUNT DUE $_________

A check is enclosed payable to Self Psychology Fund.

Bill my: VISA MasterCard

Account #___________________________________________________________

Exp. Date__________________

Signature____________________________________________________________
(as it appears on the card)

______________________________________________________________
Street Address on Credit Card Billing Statement

______________________________________________________________
City, State or Province Country Zip/Postal Code

Mail to:
Self Psychology Conference
7916 Convoy Court
San Diego, CA 92111-1212, USA
Phone: 858-565-9921
Fax: 858-565-9954

A $25.00 U.S. fee will be assessed for returned checks.

NOTE: Please make hotel reservations directly with the Marriott Wardman Park Hotel.