Annual Conference Registration In-Person Attendance Please complete the form to attend the KYCPG Annual Conference in person, in Bowling Green, Kentucky. Go back to the Annual Conference page. FacebookThis field is for validation purposes and should be left unchanged.Contact InformationName(Required) First Last Credentials Phone(Required)Email(Required) Job Title(Required)Organization/Agency Name(Required)Organization Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Continuing Education Units (CEUs)Will you be requesting Continuing Education Units (CEUs) for attendance?(Required) Yes No For which board are you requesting CEUs?(Required) Kentucky Board of Licensed Professional Counselor Kentucky Board of Social Work Kentucky Board of Alcohol and Drug Counselors Kentucky Board of Psychology International Gambler Counselor Certification Board Are you a KYCPG member?(Required) Yes No Are you a Kentucky resident?(Required) Yes No Member RegistrationMember Attendance Options(Required) Full Conference – $75 First Day: March 19 – $60 Second Day: March 20 – $30 Full Conference40 seats availableFull Conference Member Registration Price: First Day: March 1940 seats availableFirst Day Member Registration Price: Second Day: March 2040 seats availableSecond Day Member Registration Price: Non-Member RegistrationNon-Member Attendance Options(Required) Full Conference – $100 First Day: March 19 – $75 Second Day: March 20 – $45 Full Conference40 seats availableFull Conference Non-Member Registration Price: First Day: March 1940 seats availableFirst Day Non-Member Registration Price: Second Day: March 2040 seats availableSecond Day Non-Member Registration Price: Kentucky Resident RegistrationThis year’s conference is offered at zero costs to Kentucky residents. Funding for free registration is made possible by the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities (DBHDID).Kentucky Resident Registration40 seats available Price: Home Address(Required)Please provide your home address. Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Out-of-State Resident ScholarshipRegistration scholarships may be available for prevention specialists and counselors affiliated with Community Mental Health Centers (CMHCs), and all attendees are welcome to apply based on need. If you choose to apply, please complete the short description field and proceed with paid registration. Applications will be reviewed after submission, and those selected for a scholarship will receive a refund of their registration fee.Would you like to apply for a registration-only scholarship?(Required) Yes No Please provide a brief statement of need for scholarship consideration.(Required)Payment InformationTotal Credit Card Billing Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Credit Card(Required)