Clinical Practice Workshop Registration Form

Friday April 13 or Saturday April 14th, 2012 10am - 4pm

If you are paying by Credit Card, the address you give must be the address at which you receive your Credit Card Bill.

* = Required

Salutation Mr. Mrs. Ms * First: * Last:

* Street 1 : Street 2:

* City: * State/Prov.: Zip: * Country:

* Home Tel.: * Bus Tel.: * Date of Workshop :

E-mail: Confirm E-mail:

* By placing an 'X' in the box to the left, I agree to the following: I understand and agree that all cancellations must be made no later than 72 hours prior to the workshop date.

Payment Information

Fee is $90.00

Payment By: Name on Card:

Card No . Card Expires

Security Code What is the security code?
If you are Not paying by credit card, enter 00 in the Security Code Box above.

Signature (if mailing or faxing ) _______________________________________ Date ________________

You may make your payment by faxing your Name and Credit Card info to: 845-267-2736, or you may Call 845-268-0283 and leave the info on our answering machine, or you may send the payment via US Mail to:

Joe Soll, CSW
74 Lakewood Drive
Congers, NY 10920-1710

If paying by check, make the check out to Joe Soll

Please press the SUBMIT button below

To get more information or to sign up by phone: call 845-268-0283
or send E-mail to us at joesoll@adoptionhealing.com