HBCU Counseling Center Conference

7th Annual Historically Black Colleges and Universities
Counseling Center Conference: Mental Health Among black College Students

Registration is a two-step process

Complete the web form below

Submit your check or purchase order(s) (Made payable to SUBR/HBCU-MH Conference) to:
SUBR University Counseling Center
P. O. Box 12874
Baton Rouge, LA 70813

Pay by credit card, please download, complete, and fax the

Credit Card Authorization Form

to 225-771-3560.

Your registration will not be considered complete until registration fees have been received.

**Conference Registration Fees**
On or before October 19, 2012	After October 19, 2012
Professional $150	Professional $175
Student $25	Student $25

Name

(First Name)

(Last Name)

Title

(Director, Assistant Director, Counselor, etc.)

College/University

(full name, no acronyms)

Mailing Address

City

State

Zip Code

E-mail Address

ACCOMMODATIONS: If you require special accommodations to permit your attendance or participation, please provide your written request here:

Southern University and Agricultural and Mechanical College

HBCU Counseling Center Conference