Children’s Group Therapy Association
P.O. Box 521
Watertown, MA 02472
www.cgta.net

CONFERENCE COMMITTEE
Sandy Houde, LICSW, Co-Chair
Pam O'Callaghan, M.Ed., Co-Chair

Regina Cancelliere Casey, LICSW
Karen Caprenter, APRN, SNPJD
Jim Caron, Ed.D., CGP
Hyaeeun Sophia Chun, MSW
Sandy Houde, LICSW, CGP- Conference Assistants
Heather McKeone, MSW
Pam O’Callaghan, M.Ed., NCC- CEU coordinator
Amy Porreca, MSW - Registration Coordinator
Adele Pressman, MD
Jennie Shaw, LICSW


THE CHILDREN’S GROUP THERAPY ASSOCIATION

CGTA was established by a group of professionals actively involved in the field of children’s group therapy. The association functions as a support system for group therapists, and as an advocate for quality group services for children, adolescents and parents. CGTA is committed to providing training opportunities, and expanding resources and networking in the field. Membership in CGTA is open to all professionals invested in child and adolescent group therapy.

2011 - CGTA FALL CONFERENCE REGISTRATION FORM

PLEASE REGISTER EARLY
Mail in registration must be postmarked by October 14th

To print this page: Press "Print Screen" or Go to "File", select "Print".
Duplicate as needed. Registration must be postmarked by October 14th.

Name: _________________________________ License/Degree:____________
Profession: ________________________________________________________
Address: ____________________________________
City:________________________________________State:_______Zip:_______
Home Phone: ( )____________________Work Phone: ( ) _______________
E-mail:_____________________________________
Name of Organization: ____________________________________________

Detach and Mail to: CGTA Conference, Pam O’Callaghan, 14 Knight Rd., Framingham, MA 01701.
For more information call: 617-740-2115, or visit our website: www.cgta.net.
Confirmations will be sent by email or phone.

Pre-registration postmarked by 10/14/11 (includes luncheon and cost of CEUs)
$ 80.00 Non member
 ___________
$ 60.00 CGTA Member
 ___________
$ 50.00 Student/Unemployed Professionals
 ___________
   
10% Discount for groups of 5 or more registering together (sent in together)  

Membership:
__ I am joining CGTA with this application (pay member rate for Conference)
__ $50.00 Full __ $30.00 Student __ $90.00 Institutional
2 years membership:
__ $85.00 Full __ $50.00 Student __ $150.00 Institutional
New Membership:
 ___________
Renewing membership:
 ___________

Total - Payable to "CGTA": $

Cancellation Policy: Refund requests must be made in writing and postmarked by October 1, 2011 and are subject to a $25.00 administrative fee.
Detach and Mail to:

    CGTA Conference
    c/o Pam O'Callighan
    14 Knight Rd.
    Framingham, MA 01701

For more information call:

    Pam O’Callaghan
    :617-740-2115
    or visit our website www.cgta.net