REGISTRATION FORM |
Name _____________________________________________________________________________ |
Address _____________________________ City ___________________ State _____ Zip __________ |
E-mail _________________________________ Phone ______________________________________ |
Advanced General Registration, Postmarked by 9/30/2005, Number of registrants _____ x $75 = $_____ |
General Registration, Postmarked after 9/30/2005 OR onsite, Number of registrants _____ x $90 = $_____ |
Students and Interns with Student ID, Number of registrants _____ x $50 = $_____ |
JPA Member, Number of registrants _____ x $35 = $_____ |
TOTAL AMOUNT ENCLOSED $ _____ |
CE Certificate Requested (6.5 credits) . . . . . . . . . . _____ |
Please send me a JPA Membership Application . . . . . . . . . . _____ |
For information/Registration Requests for refunds must be in writing and postmarked no later than 10/07/2005. |
Please check discipline: __ Chemical dependency counselor __ Marriage and family counselor __ Mental health counselor __ Nurse __ Social worker __ Physician/Psychiatrist __ Psychologist __ Other ____________________ How did you hear about this seminar? ____________________________ |