TLPCA Counseling and Therapy Summit Sponsor Registration "*" indicates required fields Δ FacebookThis field is for validation purposes and should be left unchanged.Sponsor Registration ItemsName of Organization (as it will appear in the conference program):*Name of Contact Person to Receive All Sponsor Information:*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Business/Organization Website* Provide a business/organization description for the conference program.*File or Graphic for promotional purposes:* Drop files here or Select files Max. file size: 29 MB, Max. files: 3. DISCLAIMER* I agree.TLPCA does not provide a list of registrants or attendee contact information as part of any exhibit or sponsorship packages. Levels of Support and ParticipationOptions* Keynote Sponsor - $3,000 Reception Sponsor - $2,800 Luncheon Sponsor - $2,600 Platinum Sponsor - $2,400 Diamond Sponsor - $2,200 Gold Sponsor - $2,000 Silver Sponsor - $1,800 Bronze Sponsor - $1,600 Student Poster Sponsor - $1,200 Name Badge Sponsor - $1,000 Break Sponsor - $1,000 Will you be providing pre-printed inserts? (450 required)* Yes No Maybe Complimentary RegistrationsPlease provide the names of ALL of the complimentary conference attendees below, including yourself. Refer to the sponsorship information for the number of complimentary registrations.Name of Person 1 to receive complimentary registration* First Last Email of Person 1 to receive complimentary registration* Enter Email Confirm Email Name of Person 2 to receive complimentary registration* First Last Email of Person 2 to receive complimentary registration* Enter Email Confirm Email Do you need to purchase extra lunch tickets? Yes No Extra Lunch Ticket OptionYou may purchase lunch on either day for non-attendees.Friday Lunch Quantity Price: $35.00 Quantity Saturday Lunch Quantity Price: $35.00 Quantity Payment InformationTotal Payment Option* Check Credit Card Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 Security Code Cardholder Name Billing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Annual Conference2026 Call for Proposals General Info Location CE Information Sponsors & Exhibitors Opportunities Sponsor Registration Exhibitor Registration & Other Options