SUPPORT CENTER WORKSHOP REGISTRATION FORM

 Please submit one form for each participant.

Please print and mail completed registration form and check or credit card information to:
Support Center for Nonprofit Management
305 Seventh Avenue, 11th Floor
New York, NY 10001-6008

OR

Print and FAX with credit card information to 212-924-9544.

FIELDS WITH AN ASTERISK (*) ARE REQUIRED FIELDS

* Please check one:  Mr. Ms.
* Name:
Organization:
Title:
* Billing Address:
* City:
* State:     * Zip + 4:  
* Work Phone:
* Alternate Phone:
(for cancellations)
Fax:
*E-Mail:
* Is this your first Support Center workshop?  Yes   No


* Check sector from:  Nonprofit  Government  For Profit  Individual
PRIORITIZE up to 3 categories that best describe your organization's work
(1=most descriptive, 2=next most descriptive, only check 3)
Aging
HIV/AIDS
Arts/Culture
Child Care/Childhood Development/Child Welfare
Environment
Family Violence
Health
Hunger
Mental Health/Mental Retardation/Development Disabilities
 Literacy/Education/Library
Homelessness/Housing
Immigrant/Refugee Support
Juvenile Justice/Parolees
Philanthropy/Grantmaking
Religious
Vocational/Job Training
20+ employees
40+ employees

To determine the appropriate fee, select your agency budget below (total support and revenue from the last fiscal year). Please note: Some workshops have additional fees associated with them. Please see workshop descriptions.
       Agency Budget Half Day Full Day
$0 - 199,999 and unaffiliated individuals $ 60 $ 80
$200,000 - 999,999 $ 95 $130
Over $1,000,000 - Under $5,000,000 $130 $180
$5,000,000 + $160 $200


If you are eligible for a scholarship, please check one of the following and submit required information with your registration form and payment. Scholarships are awarded on a first-come first-served basis.

NYSCA    Altria Scholarship Program    United Way NYC    


Workshop # Workshop Title Date Fee Total
* * * * *
              
              
              
Materials Fee:   
Total Enclosed:   




If you are paying by credit card, you must complete all the information in this section.
Credit Card Number:
Visa    MasterCard    American Express
Name on Card:
Expiration Date: 3-Digit Security Code:
* Signature:
* Is the billing address for the credit card the same as the address above?Yes   No
If no:
Billing Address:
City:
State:     Zip + 4:  

FOR OFFICE USE ONLY:
Date Received: Date Entered:
Event Paid With: Amt. Received:
Invoice: Balance Due:
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