(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]