“The Many Faces of Addiction ” - Fond Du Lac Tribal and Community ...

Please check all that apply :
MN/UMICAD CD Counselor Rates Non-CD/UMICAD or Non-Resident rates
___ Full Conference $100.00 ___ Full Conference $250.00
___ Monday, July 29 $30.00 ___ Monday, July 29 $60.00
___ Tuesday, July 30 $30.00 ___ Tuesday, July 30 $60.00
___ Wednesday, July 31 $30.00 ___ Wednesday, July 31 $60.00
___ Thursday, August 1 $30.00 ___ Thursday, August 1 $60.00
___ Friday, August 2 $30.00 ___ Friday, August 2 $60.00
___ Thurs - Fri, Aug 1-2 $50.00 ___ Thurs - Fri, Aug 1- 2 $100.00
Payment: Please make checks or purchase orders payable to Fond du Lac Tribal and Community College or
FDLTCC. No refunds will be made after July 19, 2013 unless application is refused.
___ Enclosed is a check or money order Check # __________________________________________________
___ Enclosed is a letter of authorization and/or purchase order made out to FDLTCC.
___ Credit card payment Circle one: Visa MasterCard Discover
Credit Card Number: ____________________________________________ Exp Date ______________________
Printed Name: ________________________________________________________________________________
Address: ____________________________________________________________________________________
City: __________________________________________ State: ________ Zip Code: ______________________
Signature: ________________________________________________ 3-digit CVS Code: ___________________
MEALS: All meals will be catered – please provide your own snacks. Meal tickets for unregistered guests will be
available for the following prices per person, per meal: $8.50 breakfast, $11.00 lunch, and $16.00 supper. The
MAIIADS Feast is free and open to everyone, so please invite your guests.
Please identify any special diet or health needs: ______________________________________________________
Individuals with a disability who need a reasonable accommodation to participate in this training, please indicate
your request: _________________________________________________________________________________
Mail registration to: Fax registration to:
Paula Froemke Paula Froemke
Fond du Lac Tribal and Community College 218-879-0814
2101 14th Street Questions?
Cloquet, MN 55720 218-879-0775 or pfroemke@fdltcc.edu
All requests must be submitted at least two weeks prior to the event. If you have any questions, please contact the
Office for Students with Disabilities at (218) 879-0805 (V/TTY). All registration materials are available in
alternate formats to individuals with a disability by calling (218) 879-0715 (V/TTY).
6