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CE WORKSHOP REGISTRATION FORM BRAZIL 2005

 (Please copy and send as an attachment to Sherri McCarthy [Sherri.McCarthy@NAU.EDU] or the address at the bottom of the page)

Please print clearly.

Title: Prof.    Dr.  Mr.   Mrs.  Ms.

Name: first______________________________last______________________

Full address______________________________________________________

_______________________________________Tel______________________

Fax____________________________________Email____________________

 

Please check all workshops for which you wish to register:

 

July 17th Workshops:

A____8:00 am July 17, 2005 ___Anger Management for Adolescents (4 CE credits)

B____1:00 pm  July 17, 2005  ___Gestalt Therapy Training  CANCELLED

 

July 18th Workshops

C___ 8:00 am July 18, 2005 ___Aboriginal People: Assessment of Child Protective Needs

D___1:00 pm July 18, 2005 ___Eclectic Children Psychotherapy CANCELLED

 

Cost per workshop: (all amounts in US dollars)

Category A $50    Category B $50   Category C (and students) $20

 

Number of workshops for which you are registering  ___  x  cost  = ____________

 Please check payment/method (Payment details, in US dollars):

_____Check/money order payable to: International Council of Psychologists

            (Brazilian Reais or US Dollars only. MUST BE PAID ONSITE AT ONSITE RATE)

_____Credit Card  (VISA CARDS ONLY!! Include details below)                       

            Card Holder  and Initials as  on card_______________________________

            Card Issue #_________________Card Expiry Date:_________MM/YY

            Exact billing address for credit card_________________________________________

            Name of Organization issuing card:__________________________________________   

            Telephone No.__________ Postal Address:_______________________________

 

 ICP Refund policy for CE Workshops is: A full refund is provided if written notice is given 60 days or more in advance; a 50% refund is provided if written notice is given between 60 days prior to the workshop and July 15th. No refunds are provided if notice is received after  July 15th  2005.  Send receipt____.

 Please send completed CE Registration form and payment to:

Dr. Sherri McCarthy & Dr. Claudio Hutz

Vicente da Fontoura 2570

90640-002 PORTO ALEGRE, RS, BRAZIL

OR, IF PAYING BY CREDIT CARD:  Please send as an attachment Sherri McCarthy  [Sherri.McCarthy@NAU.EDU]