Page 21 - 2019 CPI Conference Brochure

2019 Crisis Prevention Institute
INSTRUCTORS’ CONFERENCE
Scottsdale, Arizona July 14-19, 2019
Registration Form
Complete the following four easy steps for the 2019 CPI Instructors’ Conference week registration. Please print legibly in ballpoint pen.
If registering more than one person, please register online at cpiconference.com
STEP 1 — CURRENT INFORMATION
q Check here if this is a new address.
Name: ___________________________________________________________________
Instructor ID #: ____________________________________________________________
Name as it would
appear on badge: ________________________________________________________
Organization: _____________________________________________________________ Title: _____________________________________________________________________ Address: _________________________________________________________________ City: _____________________ State/Province: _________ Zip/PC: ________________ Phone: ____________________________
Email: ___________________________________________________________________
Dietary restrictions:
q Vegetarian q Gluten Free
q Lactose Free q Lactose/Gluten Free
STEP 2 — MAKE YOUR CONFERENCE WEEK SELECTION - PLEASE CHECK THE Please continue your registration by completing steps 2–4 on the next page. 
APPROPRIATE BOX BELOW.