Registration: 42nd CCNY Conference: Charting Our Course

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* This form to be used if paying by check * Questions? please call Pattie at 315-312-4416 Make Checks Payable to: Auxiliary Service-SUCO, INC (CCNY in the memo) Mail Checks to: SUNY Oswego Counseling Services, MWHC#10, 40 Rudolph Road, Oswego, NY 13126

First Name *

Last Name *

Primary Email (please check spelling) *

Institution Name *

Position or Title *

CE's Requested *

Yes

If YES to CE's, please identify your professional affiliation

Counseling

Social Work

Psychology

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Please select your Friday Take-out lunch choice (chips, fruit, snack and water) *

Chicken BLT Wrap

Chicken Caesar Wrap

Chicken Bacon Ranch Wrap

Veggie Hummus Wrap

Garden Salad (ck side will be available)

None Thank You

Please List Dietary Restrictions

Persons with disabilities, needing accommodations to attend this event, should make us aware here or call Jane at 315-312-4416

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