12th Annual Summer Institute On Addictions 
CONFERENCE and EXHIBITOR REGISTRATION
Conference Location:
The Chicago Athletic Association
12 South Michigan Avenue
Chicago, Illinois

TO REGISTER PLEASE PRINT OUT THIS REGISTRATION AND FILL IN.  MAIL TO BELOW ADDRESS WITH PAYMENT OR FAX USING CREDIT CARD NUMBER.  THANK YOU
6 CEUS per day
Lunch Included!!
Text Box: 6 CEUS per day Lunch Included!! Circle one letter per session per day

Session I

Session II

Wednesday
June 14, 2006:


Choose One

   A   B  C    
 

Choose One

D   E   F  

Thursday
June 15, 2006:

Choose One

   A   B  C    
 

Choose One

D   E   F  
 

Friday
June 16, 2006:

Choose One

A  B   C  

Choose One

D   E   F  

TOTAL CONFERENCE FEE: $__________________ *******(Lunch included in price)

Name ___________________________________________________________________________________________________________

Agency___________________________________________________________________________________________________________

Home Address ___________________________________________________________________________________________________

City, State, Zip ___________________________________________________________________________________________________

Phone (work#) ____________________________________________  Home #_______________________________________________

 Check or Money Order enclosed. Indicate here: £  Make check payable to: Haymarket Center. 

M/C # __________________________________________________________________________________________________________

VISA # _________________________________________________________________________________________________________

Expiration Date: ________________ Signature _______________________________________________________________________ 

For exhibitor only:   o Check if you need electrical outlet for your table.

****For Multiple Registrations Please Copy Form****

Mail registration to:

Ms. Carol Blyskal
Haymarket Center 
932 W. Washington Street
Chicago, IL 60607

312/226-7984 Ext. 314      Fax 312/226-8048

6 CEUs per day wil be awarded from the Ilinois Alcoholism and Other Drug Abuse Professional Certification Association, Inc. (IAODAPCA) CADC, IDPR (Social Workers), L.P.C. and L.C.P.C.

Conference Fees

Summer Institute main page