Pre-registration is required. Space is limited. There are two easy ways to register:

1. You may print out this registration form by clicking on the ‘printer’ icon to the upper right. Then mail or fax completed registration form to below address. (If you prefer, a convenient one-page PDF version of the registration form is also available in “Related Content” at bottom or by clicking here.)
   
2. Or you may pay separately and simply e-mail in this completed form to the e-mail address: creativerevolution@mindfreedom.org

Please note that payment(s) must be sent in by below deadlines or registration form will not be accepted.

Type or print legibly. List name and organization (if any) as you want it to appear on your nametag.

Mail, email, or fax registration form to below address.

Please make your check or money order payable to MindFreedom International.

Information about securely paying by credit card is at bottom.

MindFreedom International
454 Williamette St., Suite 216
P.O. Box 11284
Eugene, Oregon 97440-3484 USA

Fax: 541-345-3737

E-mail: creativerevolution@mindfreedom.org

Name ______________________________________________________

Organization (if any) ________________________________________

Address ____________________________________________________

_____________________________________________________________

City ___________ State/Province _________________

Zip/Postal Code _______________________________

Country _______________________________________

Phone _______________________________________

Email _________________________________________

Accessibility Information: Wisdom House has a ramp to get in the building, and elevators. Do you have an accomodation request? Please indicate below.

Diet ___________________________________________________________

Accessible accomodations (please describe your needs specifically):

________________________________________________________________

Service animals _________________________________________________

Other (please be specific) _______________________________________

The conference begins with registration at 4 pm on Thursday, 12 July 2007, followed by dinner at 5:30 pm. The conference will end after a 12 noon lunch, at 1 pm, on Sunday, 15 July 2007.

The total fee includes your conference fee, room and meals for the four days: several snack breaks; dinner on Thursday; breakfast, lunch, and dinner on Friday and Saturday; breakfast and lunch on Sunday.

Please check the type of room you are requesting:

Shared Room ___________ Single Room __________

Shared Room

If you want a shared room: Please indicate your preferred roommate below. If you want a shared room, but do not have a preferred roommate, one will be assigned to you. (Note: The cost for the shared room is per person.)

Early-bird registration discount for shared room:

With a shared room, if you pay a deposit of half your conference fee by 30 March 2007, you will get a discount price of $344 total fee.

You must pay $172 by 30 March 2007. You must pay the remaining fee of $172 by June 30 in order to hold your place at the conference.

preferred roommate (if any) ______________________________

Regular registration for shared room:

With a shared room, if you pay by April 30, 2007, the total cost is $370. You must pay $185, half of your conference fee, by April 30. You must pay the remaining fee of $185 by June 30 in order to hold your place at the conference.

preferred roommate (if any) ______________________________

Single Room (shared bath)

Early-bird registration discount for single room:

With a single room, if you pay a deposit of half your conference fee by 30 March  2007, you will get a discount price of $404 total fee. You must pay $202 by 30 March 2007. You must pay the remaining fee of $202 by 30 June in order to hold your place at the conference.

Regular registration for single room:

If you pay by 30 April 2007, the total cost is $430. You must pay $215, half of your conference fee, by 30 April 2007. You must pay the remaining fee of $215 by 30 June 2007 in order to hold your place at the conference.

$ ________   Registration deposit or total

$ ________ Optional contribution to scholarship fund to help others attend the conference

$ ________Total enclosed

MindFreedom is not able to provide scholarship assistance at this time. If scholarship funds are contributed, we will announce that on our website, so check the website for updates. Please check with your local mental health organizations or state-wide peer organization, etc., if you need funding for the conference.

Refund Policy: Conference registration cancellations must be received in writing. Cancellations before 1 June 2007 will be refunded, minus a $50.00 administrative processing fee, per person. Fees will not be refunded on or after 1 June 2007.

Payment Options — please check one:

___ Check or Money Order enclosed (U.S. Currency Only)

___ Credit Card:

You may pay with your credit card using the secure PayPal “Donation” form on this web site (see button on right side of home page). Or send this form with credit card information below by postal mail or fax. Never e-mail credit card information.

Check one:

____VISA  ____Discover  ____American Express ____MasterCard

Name as it appears on card____________________________

Card # ________________________________________________

Expires:_____________________  Amount:$________________

Signature_______________________________________________

Phone #: ______________________________________________

Additional materials will be sent to you after your registration.

[Below in “related content” on this web page you may download both pages of a two-pagePDF flyer about the conference/retreat, including registration form.]