Fields marked with * are required. Info will only be used for Onion River Education Network workshops.

Method of Payment:	Mail (Check) Fax (Credit Card) 802-860-1282 Online (Credit Card)
Workshop:	Houston, TX, Wednesday, January 20th, 2010 Dallas/Desoto, Friday, January 22nd, 2010
*Last Name: (For 2 registering together see Comments section below)
*First Name:
Profession:	Select Profession Social Worker/LCSW Psychologist Mental Health Counselor Licensed Professional CounselorMarriage and Family Counselor Drug & Alcohol Counselor/Addictions CounselorPsychoanalystPastoral Psychotherapist Nurse Teacher/Educator Guidance Counselor School Psychologist Student/Intern Other
NASW # (for Social Workers enrolled in the NASW)	Since we are accredited by the NASW, the NASW requests that we keep track of their members who attend our workshop. This number is not required.
*Street Address:
*City:
*State:
*Zip:
Phone Number (in case of  cancellation):
Email Address to send confirmation:
*Workshop Rate:	$179 Regular Registration $159 Early Registration (10 days early) $149 Early Registration w/2 or more $139 Registration w/5 or more
Comments: (if 2 or more registering, name  partner/s. Fill this form out separately for each person.)
Press "Register" button, then wait for Paypal payment page.	If the button doesn't work, just phone (802.865.4883) or fax (802.860.1282) us.

You will receive a confirmation and receipt when registration and Paypal payment are received.