Building Bridges: Connecting Three Counties for Mental Health and Substance Use Solutions

Building Bridges: Connecting Three Counties for Mental Health and Substance Use Solutions
Name

First NameLast Name
Agency/Organization:
Email:
example@example.com
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you need Continuing Education (CE) Credits?
If you selected Yes above, please select the type of Continuing Education (CE) Credit you need.
Do you need a Certificate of Attendance?
How would you like to pay your registration fee?
If you prefer to mail a check, please make your check payable to:

Lauderdale County Children's Policy Council

and mail to:

200 South Court Street, Suite 231

Florence, AL 35630

Please include the registrant's name on the check or memo line. Registration is not complete until payment is received.
Conference Registration
Calculation
Payment Amount

prevnext( X )
USDDescription
Registration is not complete until payment has been submitted. The conference registration fee is $45 if paid BEFORE September 25th and $60 ON or AFTER September 25th. Thank you for registering!

Debit or Credit Card

Choose from one of the PayPal options to make your payment.