Contact Name: *		Please list your contact person here. Space will be provided later to list multiple registrants.
Organization Name:
Organization Address:*
Contact Email:*
Contact Phone Number:*
Contact Fax Number:*
Membership Status:*		Yes, I belong to a MARFY Member organization.
Attendees :*		Please list the names of your attendees (maximum is three attendees per agency) and note which type of CEUs are needed and whether or not the attendee needs a vegetarian meal provided for lunch. CEU KEY: SW = Social Work; C/T = Counselor/Therapist; PA = Program Administrator; and AC = Attendance Certificate   NAME SW CEUs C/T CEUs PA CEUs AC Vegetarian Meal 1. 2. 3. If you have more than three individuals who would like to attend, please enter the additional names in the space provided below to add them to the Waiting List. If space is available for them to attend, we will notify you. Please note that these individuals are not registered to attend the symposium at this time, they are on the Waiting List:
Sponsorship Opportunities: All Sponsors will be recognized in the event program!		We would like to sponsor this event for an additional contribution of: $100 $250 $500 $1000 Other Amount: $ Please call Virginia at 410-312-3161, ext. 4 to discuss sponsorship options!
Fees:		Members: $35 per person NonMembers: $70 per person ( lunch is included in both fees)
Total Ticket Fees*:		$
Method of Payment:*		Please bill me at the address above (MARFY Members ONLY)
		I will be paying with the credit card information included below:
Credit Card Number: (disclaimer)
Expiration Date (MM/YY):
Card Type:		VISA
		MasterCard
V-code:		(Where do I find this?)
Billing Zip Code:
Name on Card:
Credit Card Billing Address: (if different from above)
Comments/Questions:
		In order to submit your registration form, you must enter the following text into the password space below: 1791 (why is this necessary?)
*Required fields.

Disclaimer: Please note that credit card information will not be processed at this time, but it is necessary to reserve registration if paying by credit card. Also note that this is not a secure website, so if you choose to submit credit card information, you are doing so at your own risk. If you would like to pay by credit card but do not want to enter your credit card information here, please fill out the rest of the form and either call or fax your credit card information in to MARFY at 410-974-4901, ext. 5 (phone) or 410-757-9530 (fax). (continue)

Password Explanation: Spambots (automated internet advertising machines that find forms such as this one online and fill them out with unsolicited advertisements) can only fill the form with their pre-set advertisements - they cannot read the text we require them to enter to proceed to the submission step of the form. The exact text indicated above must be entered for the form to submit. This security measure prohibits Spambots from sending us these unnecessary and unsolicited advertisements. If you've ever purchased anything through a website such as Ticketmaster, you've encountered a similar prohibitory measure. If you have any other questions or would like to learn how to institute this password measure on your agency's website, please contact us at www.marfy.org. (continue)