Raleigh 24 Hr. Parenting Coordination Training

*** NC 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:

$655  ____ 24 hr early bird fee        $680    ____Full fee 24 hrs           (North Carolina)

If you are from a state other than NC and require either 20 or 26 hours contact Susan at cpiandfs@gmail for the fee arrangements.

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 __________________________________________________