Atlanta-August 22-24, 2019

Parenting Coordination Training REGISTRATION FORM

Trainer:  Susan Boyan, LMFT  404-273-3370  cpiandfs@gmail.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: 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 ________________________________________________________________________________________________________________________________________

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.