26 Hr. New Orleans Parenting Coordination Training

Registration Form 

 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   ___ Judge

Business Address:  ____________________________________________________________________(street)                                      (city/town)                   (state)                       (zip code)

Phone:  (____) _________________  Mobile (_____) ________________________

E-Mail: ____________________________________________________________

 How did you hear about the training?     ____E-Mail      ____Colleague      _____Website  ____AFCC     ____ Ad

Check Training Hours/Fee:

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

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

$575  ____ Basic 20 hr early bird fee       $600  ____ Full fee 20 hrs   (Others)

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

______ 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.                                            

Card Number ______________________________________________________

Security Code __________   Expiration ___/____    Billing Zip Code ____________

Print Name of Card Holder __________________________________________________________________

Authorized Signature ___________________________________________________________________