CCCI Conference Online Application

Registration Form

CCCI Conference Friday to Wednesday, January 22 - 27, 2012

To register, fill out this form and pay securely with credit card online, or mail payment to Cross-Cultural Communications, 4220 California Street #201, SF, CA 94118. Scholarship applications are reviewed on a rolling basis: 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 $475.

Demographic Information First Name:
Last 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 FRIDAY, and to depart no earlier than 4:00 pm on WEDNESDAY. the Beachfront Conference site is not close to the airport and rush hour traffic can be difficult.

Scholarship Applicants

If applying for a scholarship, please fill out the following:

I would like to apply for a need-based partial scholarship
Text:

A few sentences about your present need, whether unemployment, full-time student status, other relevant information that you'd like our scholarship committee to know about. Disclosure of annual household income is required.

Text 2:

Please write 500 words about what you seek to learn at this conference, and what you can offer other attendees in support of their own learning. If you wish, you may submit your conference registration (with payment of the minimum $475 to hold the reservation on the next page) and email this 500 words subsequently to scholarships@effectiveinfluence.org

Please note that payment of the minimum deposit of $475 on the next page is required for this reservation to be honored: even full training scholarships will not cover this amount. Questions? Email scholarships@effectiveinfluence.org

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