Name _____________________________________________________________________________
(Please print your name clearly as you want it to appear on
your conference badge. No initials, please.)
Mailing Address ____________________________________________________________________
City/St/Zip ________________________________________________________________________
Daytime Phone ________________________________ Evening Phone ________________________
Fax _______________________________________ E-mail _________________________________
Degree/Licensures ___________________________________________________________________
Are you a member of AAMFT? o Yes o No
Are you a presenter? o Yes o No
Registration (Friday
and Saturday):
o Regular Registration $75
o Full-time Student $45
o I want CEU credit for my attendance $10
Workshop Choices (Make 3 selections):
Friday Workshops: 1st _____________ 2nd _____________ 3rd _____________
o I have enclosed a check or money order payable to LAMFT in the amount of $ ________.