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.
(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
__________________________________________________________________ (street) (city/town)
__________________________________________________________________ (state) (zip code)
Phone: (_____) __________________ Mobile (_____) ___________________
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 __________________________________________________