Texas Parenting Coordination/Facilitation Training Registration Form

September 25-27, 2019

Trainer:  Ann Marie Termini | 570-586-5669 | coparent@yahoo.com

Please print legibly and neatly.  Some of the information will be included on your certificate.

Name: ________________________________________________________________________________________________________________________________________

(As you would like it to appear on your certificate. Include credentials after your name if you would like them included on your certificate)

Credentials:  ___ Masters   ___ Specialist   ____ JD ____ Doctorate ____ Other

Profession:  ___ Mental Health  ___ Mediator   ___ Attorney   ___ Other

Business Address:  ____________________________________________________________________________________________________________________________________________________________________________

Business Phone:  (_____) _______________________________               Mobile : (______) ____________________________________________________________________

E-Mail: ________________________________________________________________________________________________________________________________________

 How did you hear about the training? ___ AFCC  ___E-Mail ___Colleague ___Website

Training Location: Denton, Texas   Dates   September 25-27, 2019

 Check Training Hours/Fee:

$635  ____ 24 hr early bird fee                 $660    ____Full fee 24 hrs           (Texas, NC Requirement)

$685  ____26 hr early bird fee                  $710    ____ Full fee  26 hr fees    (LA Requirement)

Payment Amount:  $__________   Early bird rate good until 3 weeks prior to the training

______ I will mail this form with my check or money order (payable to Ann Marie Termini) to

Ann Marie Termini, 204 Crossgate Drive, Clarks Summit, PA  18411

______ I will fax, scan or email this form with my charge information  (FAX:  570-585-6807)                                                       

Card Number ____________________________________________________________________________________________________________________________________

Security Code _______________     Expiration _______/_______  Billing Zip Code __________________

Print Name of Card Holder ________________________________________________________________________________________________________________________________________

Authorized Signature ________________________________________________________________________________________________________________________________________

Cancellation Policy

In the event you cancel three weeks prior to the training date, you will receive a full refund less a $35 administrative fee.  If you cancel less than three weeks prior to the training date, there will be NO refund made. You may, at any point, attend another session or designate a substitute to attend a training session being offered by the SAME trainer.  Credit must be used within twelve months or will be voided.  CPI will only cancel training in the event of emergency or too few participants.  If a session is cancelled or postponed, the CPI will refund registration fees in full, but cannot be held responsible for any related costs, charges, or expenses. In this case, a full refund will be awarded.