----------------------------------------------------
Common Bond Institute

6th Annual International Conference on
"ENGAGING THE OTHER:" The Power of Compassion

December 1-4 2011    Site: Santa Clara University, Santa Clara, CA

REGISTRATION FORM
(Please PRINT CLEARLY, and include Email and Phone)

CONTACT INFORMATION:

NAME: ________________________________________________________

ADDRESS: Street _______________________________________________

City____________________________ State________Zip Code___________Country_________

PHONE ________________________ FAX____________________ CELL_________________

EMAIL____________________________________ WEBSITE ___________________________

[ ] I do not wish to be included in conference roster distributed to participants (City, phone, & Email only)

REGISTRATION FEES:

1) CONFERENCE PROGRAM FEES:
  EARLY Full Program Registration
     [  ]  $175  General
     [  ]  $165  Supporting Organization Member (with proof)
     [  ]  $150  Sponsoring Organization Member (with proof)
     [  ]  $  85  Full time Student (with proof of status)

  * HALF (1/2) Conference Participation Registration:
     [  ]  $100  General
     [  ]  $ 95  Supporting Organization Member (with proof)
     [  ]  $ 80  Sponsoring Organization Member (with proof)
     [  ]  $ 50  Full time Student (with proof of status)
           * NOTE: HALF Conference Registrations are for EITHER:
              Friday and Sunday -OR- Saturday and Sunday
              If Half Conf., must choose: [ ] Fri & Sun -OR-  [ ] Sat & Sun

   THURSDAY NIGHT Conference Opening ONLY Registration:
     [  ]  $  20  All
----------------------------------------------------------
2) MEALS: Conference Lunches, Dinners, and Snacks:
  For convenience and flexibility, on-site meals are available to purchase on an individul basis at the Benson Center food service (the Market Square), which is only steps away from the meeting rooms on the same floor. The very close proximity of the cafeteria also offers convenient access to grabbing a quick coffee, tea, or drink between sessions.

SUMMARY OF CHARGES
   Conference Fee        __________
   Total Amount Due    __________
   Amount Enclosed     __________

** For payment by PayPal see: cbiworld.org/Pages/Conferences_ETO_Fees.htm

CEU: 20 CEUs are approved for this conference
         [ ] I plan to register for Continuing Education Units on-site (registering and fees paid on site)

Comments: ___________________________________________________

METHODS OF REGISTRATION and PAYMENT with this form:
1. On-line by Eventbrite and PayPal: by Credit Card or Checking account withdrawal (see above link for details)
2. By Email, land mail, fax, or to: Common Bond Institute, 12170 S. Pine Ayr Drive, Climax, Mich. 49034 USA
Ph/Fax: 269-665-9393 Email: SOlweean@aol.com Web: www.cbiworld.org (Check, Money Order, Cashiers Check)
Note: Checks must be received by Nov. 17 to allow time to deposit and clear our bank. After Nov. 17 use PayPal or pay on-site)
3. By wire transfer (contact CBI for wire instructions)
4. On-Site (note late registration fees). On-site registration opens Thursday, Dec.1st at 4:30 pm
_____________________________________________________
Cancellations: $75 admin. fee for all cancellations up to 10-20-11
No refunds can be made after 10-20-11
Assignments: You may also assign your registration to someone else for participation at no charge (assignments must be made prior to the conference date in person by phone or in writing directly to Common Bond Institute).