Third Annual Culture Counts Conference Registration

PLEASE NOTE: We are unable to receive registration forms sent via mobile phone or device.  Please use a computer to ensure that your registration form is received.

The May 1st registration deadline has passed and registration is now closed.
Please note: If you have previously registered and have not received a confirmation email this means we have not received your registration. Please contact Niki DeVonish at 973-323-3454, ex.0 as soon as possible.

Name (as it should appear on your CE certificate)

Credentials

License Number

Organization

Please select your organization from the drop down list of Division of Mental Health and Addiction Services (DMHAS) contracted agencies and self-help centers that CultureConnections serves. These agencies are eligible for free attendance.

If your organization does not appear on this list, please select "public registrant" and fill in your organization's name in the field below. All public registrants are required to pay a $75 fee for conference attendance.

Public Registrant Organization

Job Title / Position at Agency

Phone

Email (You MUST provide an email address. Confirmation is sent via email ONLY.)

Street Address

City

State   Zip Code

Please use the following drop-down menus to rate your Morning AND Afternoon workshop preferences from 1 to 4, with 1 being your first choice. Please be sure to rank ALL workshops.

We will make every effort to accommodate your preferences. Due to space limitations, guarantees cannot be made.

Morning Workshop

1st

2nd

3rd

4th

Afternoon Workshop

1st

2nd

3rd

4th

Fees: Please Check One.
DMHAS-contracted agency or self-help center = Free
Public =$75. Payment must be received before a confirmation letter will be issued.

Please mail check payable to FAMILYConnections to:

FAMILYConnections
Attn: Niki DeVonish
7 Glenwood Avenue, Suite 101
East Orange, NJ 07017

**Please note that registration is not complete until you have received an email acknowledging receipt of your registration. If you have not received an email within one week of submitting your registration form, please contact us at 973-323-3454. A confirmation letter with your assigned workshops will be sent via email approximately 1 week prior to the conference. You must bring this confirmation letter to the conference as proof of registration.

Please enter the following word image into the box below. The letters are case sensitive. Do not include spaces.
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Seeing spinning arrows after hitting send? Don't worry! Your web browser is not compatable with our website but we may have received your form. Please contact us at 973-323-3454 if you have not received a confirmation of receipt email within one week.

Registered participants who wish to cancel their attendance
must do so no later than Monday, May 11, 2015.

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