Registration

2012 New England School of Addiction Studies and Prevention Studies

June 18 – 21, 2012, Bowdoin College, Brunswick, Maine

Registration

The New England School of Addiction Studies and The New England School of Prevention Studies will take place 
June 18 – 21, 2012 at Bowdoin College, Brunswick, Maine.
 You will receive, BY EMAIL, a final confirmation, directions, and other information approximately a week prior to the school. You will receive an email from neias@neias.org, neias2@neias.org, or neias3@neias.org. It is suggested that you enter these 3 email addresses in your address book or designate as “safe sender” addresses. If you require a confirmation mailed by US Postal Service, please contact NEIAS.

Application Deadline is May 7, 2012, and April 23, 2012 for special accommodation requests.

Click here to review application instructions and guidelines.

To register online, fill out the form on this web page and complete the following steps:

Enter all registration information. Information required for all applications is marked with an *. If you do not complete these fields, your registration will NOT be sent to us and you will get an error message when you click on SUBMIT FORM TO NEIAS (if you receive an error message, please review your application to be sure that all required fields have been completed). Other fields are required in individual situations. To expedite your registration, please read the form carefully.

Click on SUBMIT FORM TO NEIAS at the bottom of this page when you have completed your application.

If you change your mind, click on CLEAR FORM at the bottom of the page and no information will be sent.

If you wish to pay your deposit or tuition today by credit card or PayPal account, after you have submitted this registration, the “Registration Submitted Page” will have a link to proceed to our Shopping Cart, where you can complete that secure transaction.

Online Registration Form

*(denotes required field)

First Name: *

Middle Name:

Last Name: *

E-Mail Address: *

Alternate Email Address:

Employer:

Is this address a Home or Business address (select one):

Address Is: *

Home Work

Street: *

City: *

State: *

Zip: *

Country:

Home Phone: *

Work Phone: *

Mobile Phone:

Fax Number:

Emergency Contact Name: *

Emergency Contact Phone: *

Last 4 digits of Social Security Number

Month of Birth:

Year of Birth:

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Program and Payment Information:

Housing on campus will be in traditional dormitory rooms, located in hallways. Shared restrooms with multiple bathroom & shower stalls will be located on each hallway. There are a limited number of rooms available on campus, which will be assigned by processed application date. All housing is in single bedrooms, charged at the single rate, unless you have a roommate. NEIAS will NOT match participants in double bedrooms unless they have requested each other. Participants may reside on campus, or commute from a local hotel or from home. Housing is only available for participants attending the full program. Partial program attendance is available for the commuter option.

Tuition Cost (select one): *

$885 - Single Bedroom Rate for Full Program (Mon. - Thurs.) $775 - Double Bedroom Rate for Full Program (Mon. – Thurs) $585 - Commuter Rate for Full Program (Mon. - Thurs.) $495 - Commuter Rate for Partial Program (Mon. – Weds.) $250 - Commuter Rate for One Course

Housing is assigned by gender (select below):

Female Male

Select below if you need a First Floor Bedroom for Medical Reasons:

I need a first floor bedroom for medical reasons

If you requested a double room, note your roommate's name below. All housing is in single bedrooms, charged at the single rate, unless you have a roommate. NEIAS will NOT match participants in double bedrooms unless they have requested each other.

Roommate:

Optional $75 Sunday Single Night Stay - select below:

Please reserve a Single Room for Sunday Night for $75:

Optional $50 Sunday Double Night Stay - select below:

Please reserve my space in a shared Double Room for Sunday Night for $50:

Optional $50 Pre-Conference Course Fee - select below:

Optional $50 for Monday Pre-Conference Course with 3 Contact Hours:

Pre-Conference Course First Choice:

Pre-Conference Course Second Choice:

Pre-Conference Course Third Choice:

Optional T-shirt - Select below:

Please reserve a T-Shirt for $10

If you have reserved a T-Shirt, please select the size below:

T-Shirt Size:

Small Medium Large X-Large XX-Large XXX-Large

If you are registering on or after June 8, 2012, please select the $50 "rush fee" below:

Rush Fee:

Rush Fee of $50 for registrations on or after June 8

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Method of Payments:

$250 Deposit Due Now:
Please indicate how $250 deposit payment and payment balance will be made. $250 Deposit Due Now:A $250 deposit - in the form of a check or money order (payable to NEIAS), credit card authorization, agency purchase order, or agency letter authorizing billing is due when registration is submitted. This applies to scholarship applicants, as most scholarships are partial. Click here for an agency billing authorization form.

Payment of Balance: Complete information about how your balance will be paid is due now. Refer to payment details and application deadlines.

Amount of agency authorization to bill on purchase order or billing authorization letter: $

Checks or money orders can be made out to NEIAS. Please note "Summer School" and your name on the check memo. Mail to: NEIAS, 75 Stone St., Augusta, ME 04330.

I am mailing a check or money order for the following amount: $

If you wish to pay your deposit or tuition today by credit card or PayPal account, after you have submitted this registration, the "Registration Submitted Page" will have a link to proceed to our Shopping Cart, where you can complete that secure transaction.

I am charging the following amount to a Credit Card or Paypal: $

If you are applying for a partial state scholarship, please indicate below. This application is NOT a state scholarship application. You must apply directly to your state for a partial scholarship. Click here for your state's scholarship application. Please note that state scholarships pay partial tuition, not full tuition.

State Partial Scholarship Application is being sent to:

Maine Massachusetts New Hampshire Rhode Island Vermont

If you are applying for a state scholarship and a scholarship is NOT awarded, please select below:

If a scholarship is NOT awarded:

Please withdraw my application I will pay my tuition My agency will pay my tuition My agency and I will each pay part of my tuition.

If your balance is not being paid in full at this time, please indicate how any remaining balance will be paid (after deposit is paid and after scholarship awards):

My balance will be paid by:

I will pay my balance My agency will pay my balance My agency and I will each pay part of my balance.

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Course Selection:
When choosing courses, carefully review the course descriptions, content levels, and target audiences for those courses that interest you. Please identify 1st, 2nd and 3rd choices by course number and name for each track. Every effort will be made to assign you to your first choice. Submit a completed registration form early to ensure that your first choice is available. Course assignments are based on the date complete applications are processed. Please note occasional circumstances beyond the control of the New England Institute may result in the cancellation of a small number of courses.

Track A Course Choices - Mon. afternoon and Tues. all day:

Track A First Choice:

Track A Second Choice:

Track A Third Choice:

Track B Course Choices (Weds. all day): Choose only B courses (unless AB or ABC).

Track B First Choice:

Track B Second Choice:

Track B Third Choice:

Track C Course Choices (Thurs. all day): Choose only C courses (unless ABC).

Track C First Choice:

Track C Second Choice:

Track C Third Choice:

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Special Accommodations:

The program site is wheelchair accessible; however, advanced notice is required in order to ensure that appropriate arrangements have been made. Application deadline is April 23, 2012 for special accommodation requests. ASL interpreters, assistive listening devices or other accommodations available upon request by deadline.

Please select from the menu below if you need a Sign Language Interpreter:

Sign Language Interpreter

Please select from the menu below if you need an Assistive Listening Device:

Assistive Listening Device

Please select from the menu below if you need Wheelchair Accessibility:

Wheelchair Accessibility

Please note any serious food allergies:

Please note any other special accommodations requested:

Security Code: Please type in the letters or numbers that you see in the box above. (An audio option is also available.) *

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