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Association of Christian Therapists Thursday 3pm - Monday 12:00pm |
Please Print or Type
Name: _______________________________________Email:_________________________________________
Name tag: ________________________________________________________________________________
Specialty Group Preference: (circle one)
Allied Health Associates Clergy Nurses
Pastoral Care Physicians/ Dentists Therapists
Address:_________________________________________________________________________________
City: ______________________________________ State: __________________ Zip:______________
Home Phone: _________________Work Phone: __________________ Fax: ________________________
Special Needs:_______________________________________________________________________________
Rooming (*Cost is per person, per night)
Single Room
$99
Double Room
$69
Triple Room (1 double bed, 1 twin)
$40
Total Enclosed
: (US Dollars Only) $__________ We regret we are unable to accept credit cardsRooming:
Rooms have either two twin beds or a twin and a double. Please indicate which room type you would like:
__ Single Room
__ Double Room I will be rooming with __________________
__ Triple Room I will be rooming with __________________ & ___________________
All registrations must be accompanied by a check made payable to Association of Christian Therapists
Complete and mail with your check to:
Association of Christian Therapists (ACT)
6728 Old McLean Village Drive
McLean, VA 22101-3906