SPRING CONFERENCE

The Family and the Brain:
An Integrated Circuit

Printable Registration Form

April 14-15, 2012

Please print this form, complete it, and mail it to:
Bowen Center for the Study of the Family
Georgetown Family Center
4400 MacArthur Blvd NW, Suite 103
Washington, DC 20007

Registrants paying by credit card may fax this form to 202-965-1765. Phone registration with credit card is available. Call 202-965-4400.

Make checks payable to The Bowen Center. Outside the US, please use a money order or credit card.

Name: _______________________________________
Organization: __________________________________
Address: _______________________________________
City, State, Zip, Country: __________________________
Daytime Phone: _____________________
E-mail: _________________________
Credit Card: Visa / Mastercard / Discover
(Please circle appropriate card)
Credit Card No: ___________________________________
Expiration Date: _______

The registration fee is refundable less a $75 administrative charge before March 22, 2012, and is nonrefundable after that date.