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One Goal Summer Conference and Logo

Check Payment Conference Registration Form



Fill in the online registration form and mail it with your check, credit card information, or purchase order to: ATTN: Frankie Allen, Conference Coordinator, One Goal Summer Conference, 13177 Old Settlement Road, Tallahassee, FL 32309.

Please note, your credit card information will not be stored in any database anywhere. It will be securely transmitted electronically only to one person who will manually enter and process your registration fee. At that time, your credit card will be charged (and processed through the Creative Center for Childhood Research & Training).

If you choose to mail in your registration form, we must receive it by July 13, 2017.
Use your Tab key to move from one field to another:

Name (as you wish it to appear on your name tag, registration confirmation, etc.):
First Name: MI: Last Name:

Title/Position:
Organization:

Mailing Address:
Address1:
Address2:
City: State: Zip:

Contact:
Primary Number (with area code):
Cell Phone Number (with area code):
Email Address for Confirmation:

Registration Fees: (must be submitted by July 13)
Conference: $75/person
Research Presentation includes lunch: $35/person (space limited)
Number attending:
Number for Conference:
Number for Research Presentation:
Total Due (calculate based on the numbers attending and the fees provided above):

Mailing (Select One):
Check (made payable to Creative Center for Childhood Research & Training (CCCRT))
Purchase Order (made payable to Creative Center for Childhood Research & Training (CCCRT))
Credit Card
What type of credit card will you be using?
Visa
Mastercard
American Express

Card Number:
Expiration Date:
C.I.D. Code:
The C.I.D. Code is the 3-digit code on the signature line on the back of MasterCard and Visa cards or the 4-digit code on the front of America Express cards above the credit card number.

If your billing address is different than your mailing address above, please provide your complete billing address here:
Please provide your name as it appears on the credit card you are using:
Name on Card:
Address1:
Address2:
City: State: Zip:

By digitally signing this form, you are authorizing us to charge your credit card the registration fee.
Signature:





Please submit this form with payment to:
Frankie Allen, Conference Coordinator
One Goal Summer Conference
13177 Old Settlement Road
Tallahassee, FL 32309.