Conference Registration

Please print and complete this form by September 28 and mail it with payment to: CMHCWNY, Inc., 814 Kenmore Ave., Buffalo, NY 14216

Name ____________________________                   

Address___________________________

_________________________________

Phone_____________________________

Email_____________________________

Agency____________________________

_________________________________

County_____________________________

Please Check One:

__Youth (under 21)           $10

__Family Member (over 21)      $20

__Family of 3               $35

($7 per additional family member)  

__Professional               $45

Checks should be made payable to the Children’s Mental Health Coalition of WNY, Inc.

Registration is not refundable.

Registration includes continental breakfast and lunch.

For more information on special dietary needs or overnight accommodations, call us (716) 871-8997