REGISTRATION FORM - Print, Fill Out and Mail

SPECIAL DISCOUNTS IF YOU REGISTER NOW FOR MORE THAN 1 WORKSHOP:

1 Workshop = $119                         3 or 4 Workshops = $108/each
2 Workshops = $114/each                      5 or more Workshops = $103/each

Workshop discounts must be pre-paid and can be used by one person (not multiple people)
Add $10/per workshop for Psychologist CE Credit

NAME ___________________________________

POSITION ___________________________ORGANIZATION _____________________________

Please indicate where you prefer to receive mailings: HOME ____ WORK _____

ADDRESS _______________________________________CITY _________________________

STATE ______ZIP ________ E-MAIL ADDRESS ___________________________________

WORK PHONE ___________________ HOME PHONE _________________________

I want CE credits for:
___ Social Worker CE - ___LICSW ___LCSW ___LSW - Lic # _________________  NASW # _________________
___ MH Counselor CE - Lic # _________________
___Natl Cert Counselor CE    ___Nurse Contact Hours    ___Marriage & Family CE   
___Substance Abuse or LADC CE    ___Psychologist CE ___Educator Certificate   

Dates Location Workshops Fee
Wednesday, March 16, 2011 Doubletree Hotel, Burlington, VT Life After Anxiety: How to Replace Fear & Worry with Positive Alternatives $119
Wednesday, April 27, 2011 Doubletree Hotel, Burlington, VT Clinical & Ethical Challenges with High Risk Behaviors $119
Friday, May 20, 2011 Doubletree Hotel, Burlington, VT All the Rage: Best Practices for Helping Adolescent Girls in Crisis $119
Tuesday, June 28, 2011 Doubletree Hotel, Burlington, VT Bullies, Victims & Bystanders $119
Wednesday, July 13, 2011 Doubletree Hotel, Burlington, VT Can We Teach These Kids to Dance: Trauma & Attachment Informed Treatment $119
Thursday, August 11, 2011 Doubletree Hotel, Burlington, VT Anger, Rage & Trauma: Talking to Kids About Difficult Things $119
Total number of Workshops ____at $ ____each = TOTAL:$______
Psychologists - - Add $10 CE Fee per Workshop = TOTAL: $______
TOTAL FEE: $______
All Major Credit Cards Accepted
All major credit cards accepted

Please charge my: MC__ VISA__ DISCOVER__ AMEX__

CARD #________________________ EXP. DATE_________

SECURITY CODE #________ SIGNATURE____________________________

Mail with your non-refundable check to the address below or fax to: 978-535-1557.

Community Program Innovations, Inc.
471 Broadway, Lynnfield, MA 01940.

Payment must accompany registration form.