Canadian Group Psychotherapy Association
Ottawa Ontario, May 9-12, 2012
PERSONAL DATA
Please check preferred salutation:
Dr.
Mr.
Ms.
Mrs.
Miss
*Last Name: ________________________________ *First Name: _________________________________________
Job Title: _______________________________ *Affiliation/Organization: ___________________________________
*Address: ______________________________________________________________________________________
*City: __________________________ *State/Province: _________________ *Zip/Postal: ____________________
*Phone: ________________________________ *Email: _______________________________________________
I consent to the inclusion of my name and contact information, provided above, in the conference participant list, which
may be distributed to the organizers, sponsors, and delegates:
Yes
No
I consent to the inclusion of my name and contact information in the CGPA mailing list:
Please send me information on CGPA membership
Yes
Yes
No
No
Please indicate if you have any food allergies or other special requirements: ________________________________
_____________________________________________________________________________________________
I will attend the Gala Dinner Dance on Friday, May 11th. Note this is included for Full or 2-Day Conference
attendees. One day attendees & guests may attend at a cost of $30.00.
Yes, I will attend
No, I am unable to attend
I will be bringing a guest (please pay this on site at the Hospitality Desk)
I will attend the Thursday evening reception to launch the Psychotherapy Practice Network
Yes, I will attend
No, I am unable to attend
I will attend the Saturday CGPA Annual General Meeting. Note attendance is encouraged for CGPA members.
Lunch is provided.
Yes, I will attend
No, I am unable to attend
WORKSHOP SIGN-UP
The Full 3-Day Conference registration fee includes: admission to the workshops on Thursday, May 10th and Saturday, May 12th
and the all day workshop with Susan Gantt on May, 11 with refreshments daily.
The Two Day Conference registration fee includes: admission to the session on Thursday May 10 th/ Friday, May 11th, or Friday,
May 11th/ Saturday, May 12th with refreshments on the days chosen.
The One Day Conference registration fee includes: admission to the session on the day of your choice, with refreshments on the
day chosen.
The Preconference Training Session registration fee includes: admission to the workshop all day on Wednesday, May 9 th and
refreshment breaks.
The Postconference Process Group includes: admission to the full day workshop on Saturday, May 12th and refreshment
breaks.
Please place a check next to the events that you will be attending.
Conference Registration Fees
Early Bird
(Before April 15th)
/Standard
From April 16th
Pre Conference Training
Wednesday Training :
Beginner
Intermediate
Advanced
1-Day Conference
Thursday Half Day Morning/ Afternoon W/S
(Thursday AM/ PM Workshop Choices)
___________________________________________
Thursday All Day Workshop
Friday All Day Workshop
Saturday Half Day W/S
(Saturday AM Workshop Choice)
____________________________________________
2-Day Conference Thursday/Friday,
or Friday/Saturday workshops
Thursday and Friday
(Thursday AM/ PM Workshop Choices)
___________________________________________
(or
Thursday All Day Session)
Friday and Saturday
(Saturday AM Workshop Choice)
____________________________________________
Full Conference ( Thursday ,
Friday and Saturday Workshops )
(Thursday AM /PM Workshop Choices)
____________________________________________
(or
Thursday All Day Session)
Saturday Workshop Choice
____________________________________________
Additional Details
PAYMENT INFORMATION
Payment can be made by Credit Card
Payment can be made via credit card by completing the online registration.
Payment by Cheque
If paying by cheque, please complete this registration form and forward with your cheque. Note the following:

If you are sending the cheque by mail it must reach our office at least 10 days prior to the conference date.

All cheques must be drawn on a Canadian bank and be in Canadian funds

Please note the registrant’s name on the face of the cheque
Cheques should be made payable to:
“CGPA”
Payment mailed to: 20 Crestfield Drive, Hammonds Plains , Nova Scotia, B4B1E7
Registration Forms faxed to: 902 473 7126
Physicians
Mental Health Workers
Students & Retired
1 Day
2 Day
3 Day
1 Day
2 Day
3 Day
1 Day
2 Day
3 Day
$250.00
$375.00
$475.00/525.00
$175.00
$250.00
$365.00/415.00
$125.00
$175.00
$230.00/260
CGPA Members deduct $35.00 (+15 if attending Pre/Post)
$
$
$
$- 35.00
(or 50.00)
Pre and Post Conference Activities
Pre Conference Training
$125.00
Process Group full day
experiential group
Saturday, May 12th
$125.00
Gala Dinner Guest
$ 30.00
TOTAL
$
$
$
$
Further Information
Confirmation
Your registration and payment will be confirmed by email. Please use this confirmation as your registration receipt.
Refund Policy
As some expenses are incurred prior to the start of the conference, it is necessary to impose the following cancellation policy:
Date
Penalty
Up to May 1st
$50.00
May 2 onwards
No refund
There are no refunds after May 1st however; a substitute attendee from the same organization is permitted at any time prior to the
conference date at no additional charge. All cancellations must be received in writing via email. Refunds will be issued by cheque
or credit card.
For registration information or questions please contact: Carolyn Sinyerd at canadiangpa@gmail.com
Thank you for registering and we look forward to welcoming you to Ottawa