Register

REGISTRATION

Name_________________________________________________________________

Address_______________________________________________________________

City______________________ State______Zip___________________

Phone_________________________e-mail address_________________________________

LMSW or LCSW? ________­­­_  LAPCor LPC?______Other? _______________

any individual who registers for 3 or more workshops take $10 off TOTAL registration fee.  Call for group discounts. ENTER THE NUMBER  AND DATE OF WORKSHOP(S)

ATTENDING:___________________________________________________________________

Total Amt$_____________ Credit card? VISA______MasterCard_____

Card Number ______________________________________________

Name on Card__________________________________________________________________

Billing address__________________________________________________________________

Expiration Date___________________