School Safety Advocacy Council (SSAC) (941) 232-4633

2013 National Bullying Conference Registration

First Name

Last Name

Agency / District

Mailing Address

City

State

Zip		*required field

Work Phone

Cell Phone

Email Address		*required field

Fax Number

Registration Type		$400 - Early Discounted Attendee Registration (Prior to 12/31/2012)

		$425 - After 12/31/2012

		$350 - Early Discounted Multiple Attendee Registration (5 or More from same agency prior to 12/31/2012)

		$375 - Multiple Attendee Registration (5 or more from same agency after 12/31/2012)

		Student Registration - $199 (Under the age of 18 enrolled in grades 6-12)

Payment		Check (will be sent) Pay by Credit Card

		If paying by Credit Card Click Here

Promotion Code:



IP Address will be logged upon registering

* $100.00 Fee For Cancellations After 1/16/2013

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