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:

$705  ____26 hr early bird fee                  $730    ____ Full fee  26 hr  (LA)

$655  ____ 24 hr early bird fee                 $680    ____Full fee 24 hrs  (NC, Others)

Payment Amount:  $__________   Early bird rate good until 3 weeks prior to the start date (September 10, 2020)

______ 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 ___________________________________________________________________