NCABA Membership, Conference, and Workshop Registration Form

Instructions: You can use the form below to complete membership, conference, and conference workshop registration. Please complete all information. Be sure to submit your entry when it is complete by pushing the submit button at the bottom of the page. When you submit the form you will be asked to choose your payment method (mail, fax, phone, and online payments by check are available). Your registration is not complete until payment has been received. Membership registration below is for the period of January 1st through December 31st 2010. The conference registration and workshop registration below are for the NCABA Conference February 17th through February 19th, 2010.

Full Name: Affiliation:
Mailing Address:
City: State: Zip Code:
Email: Home Number:
Work Number: Fax Number:
Major Field of Study: Highest Degree Earned:
Licensure or Certification: Specialty Area:
Check One: Membership Renewal Renewal with Changes New Application Not Applying for Membership
Membership Fee: None
(Choose this option if you are registering for the conference only)
Full Membership = $20.00
(Anyone interested in the study of behavior analysis or employed in a profession or vocation that utilizes the principles of behavior analysis, these individuals may vote and hold elected office)
3 Year Full Membership = $50.00
(anyone wishing to pay in advance for full membership for three years)
Paraprofessional/Parent Membership = $10.00
(available for individuals who are not academically trained in the study of behavior analysis, these individuals are eligible for reduced membership rates, but may not vote or hold elected office)
3 Year Paraprofessional/Parent Membership = $25.00
(anyone wishing to pay in advance for paraprofessional/parent membership for three years)
Student Membership = $10.00
(a student who is currently enrolled in a course of study on at least a half-time basis at an accredited college or university who is interested in the application of behavioral principles)
Conference Fee: None
(Choose this option if you are registering for membership only)
Full Member Registration = $80.00 if submitted after 01/22/10
(Choose this option if you are already a current full member or if you are registering as a full member above)
Paraprofessional/Parent Registration = $50.00 if submitted after 01/22/10 (Choose this option if you are already a current paraprofessional/parent member or if you are registering as a paraprofessional/parent member above)
Student Registration = $30.00 if submitted after 01/22/10
(Choose this option if you are already a current student member or if you are registering as a student member above)
Non-member Registration = $110.00 if submitted after 01/22/10
(Choose this option if you are NOT a current member and are NOT registering for membership above - Note that becoming a member of NCABA will save you $30.00 on conference registration)
Conference Workshop Fee:
(check all that apply) 		Workshops below are co-sponsored by the North Carolina Psychological Association and the North Carolina Association for Behavior Analysis. The North Carolina Psychological Association is approved by the American Psychological Association to sponsor continuing education for psychologists. The North Carolina Psychological Association maintains responsibility for the workshop and its content. Each workshop is offered for 3 hours of continuing education credits.
None
Pre-Conference Workshop I (Miltenberger): Wed. February 18th 9:00 AM (description)
Pre-Conference Workshop II (Schell): Wed. February 18th (description)
Pre-Conference Workshop III (Thompson): Wed. February 18th 9:00 AM (description)
Post-Conference Workshop V (Vollmer): Fri. February 20th 1:30 PM (description)
Post-Conference Workshop VI (Ludwig): Fri. February 20th 1:30 PM (description)
Post-Conference Workshop VIII (Stuart/Golden): Fri. February 20th 1:30 PM (description)

Fee for One Workshop: if submitted after 01/22/10 = $80.00
Fee for Two Workshops: if submitted after 01/22/10 = $130.00
Student Workshop Rate: if submitted after 01/22/10 = $30.00
Student Workshops Rate: if submitted after 01/22/10 = $50.00

BCBA
CEU Fee:
None
BCBA CEUs = $30.00 (select if you would like to receive BCBA CEUs for conference and/or workshop participation). There are 17 Type II BCBA CEUs available (6 for attending any two BCBA approved workshops & 11 for attending sessions in the regular program). All credits that are approved will be available for this additional fee. A blue asterisk is beside each session in the agenda for which approval was received. The fee is the same regardless of the number of credits earned during the conference.
Calculate total owed from the four fee sections above. Please record the amount here and remember it so that you can complete payment after you submit this form. Total Amount Owed : $

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