Atlanta-August 22-24, 2019
Parenting Coordination Training REGISTRATION FORM
Trainer: Susan Boyan, LMFT 404-273-3370 email@example.com
Please print legibly and neatly. Some of the information will be included on your certificate.
(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 : (______) ____________________________________________________________________
How did you hear about the training? ___ AFCC ___E-Mail ___Colleague ___Website
Training Location: Atlanta, GA Dates August 22-24, 2019
Check Training Hours/Fee:
$575 ____ Basic 20 hr early bird fee $600 ____ Full fee 20 hrs
$635 ____ 24 hr early bird fee $660 ____Full fee 24 hrs (NC)
$685 ____26 hr early bird fee $710 ____ Full fee 26 hr fees (LA)
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 Susan Boyan) to
The C.P.I. at 1936 A. North Druid Hills Road, Brookhaven, Georgia 30319.
______ I will Venmo my fee to Susan-Boyan
______ I will fax, scan or email this form with my charge information (FAX: 404-982-0006) Add a $15 charge for using credit or debit.
Card Number ____________________________________________________________________________________________________________________________________
Security Code ________ Expiration _____/_____ Billing Zip Code ____________
Print Name of Card Holder ________________________________________________________________________________________________________________________________________
Authorized Signature ________________________________________________________________________________________________________________________________________
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.