CONFERENCE REGISTRATION FORM
20th Annual Conference on The Psychology of The Self
CHALLENGES IN SELF PSYCHOLOGY 


 Print this form and mail with payment to the address listed below.

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.  Please use one form per registration. 

(Please print or type)


Last Name ______________________________________________Degree(s) __________________
                                                        (printed on your name tag)

First Name __________________________________________ Middle Initial _______________
           
Address ____________________________________________________________________________

City ______________________________________State __________Country _________________

Postal Code _______________________Phone Number (_____)_____________________________

Fax Number (_____) _______________________E-mail ___________________________________
                                          State
Profession_______________________________ Prof'l License No.________________________
                                          (for Continuing Education Certificate)
Mailing Label Code:   INTERNET 

PRE-CONFERENCE REGISTRATION FEES   		Postmarked     Postmarked
                                   		by Oct. 13     After Oct. 13

If taken with Main Conference                    [  ] $125      [  ] $150
Student*, if taken with Main Conference          [  ] $ 60      [  ] $ 70
Pre-Conference Only                       	 [  ] $150      [  ] $175
Pre-Conference Only - Student             	 [  ] $ 80      [  ] $ 90   

Pre-Conference Courses (Select one):   [  ]Introductory Course    

[  ]Advanced Course  [  ]Child Therapy Course  [  ]Brief Therapy Course

[  ]Marital and Family Therapy Course

PRE-CONFERENCE ADVANCED COURSE
If you are registering for the Pre-Conference Advanced Course, please indicate your 
choices for the Master Classes (small supervisory groups) in order of preference 
from 1-5.  YOU MUST ATTEND THE GROUP TO WHICH YOU ARE ASSIGNED.  Assignments will 
be made on a first-come, first-served basis.   
     _____Bernard Brandchaft, MD                  _____Arthur Malin, MD
     _____James L. Fosshage, PhD                  _____Sheldon Meyers, MD/Paula Fuqua, MD
     _____Ruth Gruenthal, MSW                     _____Estelle Shane, PhD
     _____Alan R.Kindler,MD/Shelley R.Doctors,PhD _____David M. Terman, MD
     _____Frank M. Lachmann, PhD                  _____Marian D. Tolpin, MD
     _____Joseph D. Lichtenberg, MD               _____Paul H. Tolpin, MD
*Student registrations MUST be accompanied by a letter from the training 
director verifying full-time status;  photocopies of student ID will not 
be accepted.  




MAIN CONFERENCE REGISTRATION FEES  		Postmarked     Postmarked
                                  		by Oct. 13     after Oct. 13

     Professional                                 $295            $325
     Student*                        	          $150            $175

*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 your preferred sessions.

ORIGINAL PAPERS AND WORKSHOPS: Please refer to the program and indicate your 
preferences in the spaces provided. Please Note:  For further information
about the Panel or Original Paper/Workshop sessions, please visit Selfpsychology website.

SESSION A:  Saturday Morning  10:30 am - 12:00 pm

First Choice No.________ Second Choice No.________     Third Choice No.________

SESSION B:  Saturday Afternoon 2:15 - 3:45 pm

First Choice No.________ Second Choice No.________     Third Choice No.________

SESSION C:  Saturday Afternoon 4:15 - 5:45 pm

First Choice No.________ Second Choice No.________     Third Choice No.________

SESSION D:  Sunday Morning 8:30 - 10:00 am

First Choice No.________ Second Choice No.________     Third Choice No.________

OPTIONAL SATURDAY LUNCHEON: An optional luncheon will be held on Saturday 
beginning at 12:15 pm.  The fee for the lunch will be $35 in advance, $40 at the
conference (based on space availability).

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

                                                In Advance      At the Conference
     Guest Cocktail Reception Ticket              [  ] $30          [  ] $35
     Guest Breakfast & Cocktail Reception Ticket  [  ] $60          [  ] $65
     Guest Luncheon Ticket                        [  ] $35          [  ] $40

Guest's Name_______________________________________________________

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

___________________________________________________________________________________

TOTALS:
Pre-Conference Fee                 $_________     [   ] A check is enclosed payable
Main Conference Fee                $_________           to Self Psychology Fund.
Optional Luncheon for Registrants  $_________
Guest Tickets                      $_________     [   ] Bill my [   ] VISA
TOTAL AMOUNT DUE                   $_________                   [   ] MASTERCARD

Account #__________________________________________________ Exp. Date__________________

Signature_____________________________________________________________________________
         (as it appears on the card)

Mail to:            Self Psychology Conference
                    7916 Convoy Court  San Diego, CA 92111 
                    Fax: 619-565-9954  (credit card payments only)

* A $15 fee will be assessed for returned checks.

NOTE:  Please make hotel reservations directly with The Renaissance Chicago Hotel.

Conference Brochure