Group Relations Conferences in the Tavistock Tradition

 
 45​th​ Annual Northwestern Group Relations Conference Registration Form 

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Title** First Name** Last Name**

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Gender* Ethnicity* Age* Sexual Orientation* Occupation* Other Identities*

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Employing Organization/School (if student)** Position Title/Job Description/Program Title (if student) Employing Organization/School Address

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Previous Group Relations Conference(s) and/or Small Study Group Consultant(s)*

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Staff/Potential Members with whom you have a relationship and do not wish to be assigned to the same Small Study Group***

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Home Address City State Zip

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Home (Area Code) Phone Other (Area Code) Phone Email Accessibility Concerns

*These items are requested to facilitate the formation of Small Study Groups of varied backgrounds and Review and Role Analysis Groups and Application Groups composed
of members with similar occupational backgrounds and/or professional roles.
**This information will be made available to members of the Conference.
*** Conference Directorate will do their best to accommodate, but cannot guarantee, these requests.
​Check appropriate fee category: 

Early registration fee (if postmarked before Friday January 3, 2020 midnight)............................................................................................$350.00

Registration fee (if postmarked after Friday January 3, 2020 midnight).............................................................................................. ........$425.00

Non-profit organizational discount*...............................................................................................................................................................$300.00

Beginning professionals discount (Graduated after 12/2017).......................................................................................................................$225.00

Non-NU student & NU-MFT student fee.......................................................................................................................................................$175.00

*To be eligible for the non-profit discount an organization must register at least three non-student members and attach a 501-(c)3 tax exemption letter.
*Inquiries about scholarships can be sent to the administrative team at [email protected].
​Payment Method:

□ Check (Payable to The Family Institute—Group Relations Conference) ​□​Amex ​□ ​Discover ​□ ​MC ​□ ​Visa

Card Holder’s Name:__________________________________________________ Card Holder’s Signature:​ ______________________________ ________________

Credit Card Billing Address & Zip:_____________________________________________________________ Credit Card #: ___________________________________

Exp Date:​ / ​ CVV (3-4 Digit Security Code):​ ​ I authorize TFI to charge my credit card for one time only for $___________________

I have read the brochure for this Conference in detail & I hereby apply for membership. I understand I will receive a confirmation of acceptance as a member and this will
constitute the contract between myself and the sponsoring institution and that my application hereby authorizes the sponsoring institution to conduct the Conference for which
I am applying in the manner described herein. I understand that the total fee must be paid by Tuesday, January 14, 2020. To resign & receive a refund minus a $25.00 fee,
requests must be received in writing by Tuesday, January 14, 2020. I understand & agree to the policies regarding refunds, confidentiality and tasks.
 Signature (Application must be signed to be processed)_________________________________________________________________________ Date / /

Applications are due Tuesday, January 14, 2020, midnight postmark; applications with a later postmark will not be processed. 

​CEUs 
Continuing Education Units (CEUs) are provided at no additional fee to those Conference staff & members with the following Illinois licensure: Clinical Psychologist, LMFT, LCPC,
LPC, LCSW & LSW. One hour of continuing education will be awarded for each hour of Conference participation, totaling 25 CEUs. If you wish to receive CEUs, please check the
appropriate box for all that apply and provide the corresponding license number (s):

□ Clinical Psychologist license # _____________________________

□ LPC/LCPC license # __________________________________________
□ LSW/LCSW license # _________________________________________
□ LMFT license # ______________________________________________
​References 
Experiential learning can sometimes prove stressful. Therefore, individuals who are vulnerable because they are physically ill or are experiencing a period of significant personal
difficulty should forgo attendance at this time. Questions about the appropriateness of your participation should be addressed to the Assistant Director for Administration through
the phone number, email, fax or mail information on the front of this packet. ​In addition to the completed Conference Application Form and payment, each applicant must   
provide two letters of reference from professionals who can document their capacity to participate in such an intensive learning experience.​ Please provide the
information requested below for two officers of your organization, faculty members, supervisors, personal therapists, and/or colleagues who know you well and can document
your personal integrity and capacity to participate in an intensive learning experience such as this. Letters from each reference should be sent to the Assistant Director of
Administration at [email protected]. References will be called for follow-up in the event letters are missing or unclear.

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Name of Recommender # 1 Title Organization

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Address City State Zip

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Phone E-mail

 
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Name of Recommender # 2 Title Organization

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Address City State Zip

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Phone E-mail
 
 
Application Deadline 
Applications must be sent in by Tuesday, January 14, 2020 or the application will not be processed.  
Please send completed application to: 
Leah Goldgar MA, LPC, NCC 
Group Relations Conference 
The Family Institute 
618 Library Place, Evanston, IL 60201 
Phone: (847)733-4300 ext. 590, Fax: (847)733-0390 
Email: [email protected]