Effective Influence Conference

Registration Form

Effective Influence Conference Thursday to Tuesday, January 7 - 12, 2010

To register, fill out this form and pay securely with a credit card online, or send payment to Cross-Cultural Communications, 241 East Third Street, Cloverdale, CA 95425 Scholarship applications are due November 15: email scholarships@effectiveinfluence.org for information. Minimum price covers room, board & meeting spaces plus free training, varying by season and # of attendees but rarely under $500.

Demographic Information

Name:
Employer:
Address: City:
State: Zip:
Daytime Phone:
Mobile Phone:
Email:

This information is requested so as to avoid inadvertent “tokening” of minority groups while maximizing diversity of opinion, and therefore value of feedback, in each of the workgroups.

Age: Ethnicity:
Gender: Male Female Orientation:
Other Identifications:

Dietary Concerns:

Ride Sharing To The Conference Site:

Limited parking is available at Pajaro Dunes.

Able to offer a ride to local atendees
Will need a ride from :
Will need a ride from San Jose Airport

Air travelers should plan to arrive at San Jose Airport no later than 2:30 pm on Thursday, and to depart no earlier than 5:00 pm on Tuesday. the Beachfront Conference site is not close to the airport and rush hour traffic can be difficult.

Agreement

I have read this brochure and hereby apply for membership in the conference.
I understand that 50% of the full price of my attendance payment is non-refundable if I cancel my reservation, since my lodgings and materials will be purchased upon receipt of my payment.
I understand that this application constitutes my commitment to attend this educational conference, and that my deposit is non-refundable. I will inform CCCI if I am unable to attend.
I understand that my commitment also extends to a short pre-reading and a 90 minute executive coach consultation by phone prior to the conference.
I am not under the care of a psychiatrist or psychotherapist, or if I am under the care of a psychotherapist or psychiatrist, I have consulted with him or her, received their explicit approval to attend an experiential process group at this time and am providing name and phone number below. (This information is requested in the rare event that a concern about your well-being arises during the conference. The staff would notify you before making any such call.)
Therapist/Psychiatrist Name
Therapist/Psychiatrist Phone Number