REGISTRATION FORM - Print, Fill Out and Mail

SPECIAL DISCOUNTS IF YOU REGISTER NOW FOR MORE THAN 1 WORKSHOP:
1 Workshop = $109                        3 or 4 Workshops = $99/each
2 Workshops = $105/each                        5 or more Workshops = $94/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 ___________________________AGENCY _____________________________

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 - Reg # _________________
___ MH Counselor CE - Reg # _________________      ___OT Contact Hours
___Natl Cert Counselor CE    ___Nurse Contact Hours    ___Marriage & Family CE   
___Substance Abuse or LADC CE    ___Psychologist CE ___Educator Certificate   

DatesWorkshopsFee
___10/26/07 "Angry?" "Resistant?" "Depressed?" "Substance Abuser?" $109
___11/1/07 DBT Strategies for Children & Adolescents $109
___11/8/07 Hope & Resiliency: Strength-Based Strategies $109
___12/7/07 Violence, Psychiatric Disorders, & Substance Abuse $109
___12/12/07 Angry & Difficult Children & Adolescents $109
___2/8/08 Can We Teach These Kids to Dance? $109
___3/7/08 Eating Disorders $109
___3/20/08 Keeping Your Cool with Challenging Youth & Adults $109
___4/4/08 Leadership Skills for Female Managers & Supervisors $109
___4/11/08 Youth Who Struggle with Social Skills $109
___5/9/08 Helping Parents Learn Parenting Skills $109
___5/30/08 What Difference Does it Make if Your Client Is a Woman or a Man? $109
Total number of Workshops ____at $ ____each = TOTAL:$______
Psychologists - - Add $10 CE Fee per Workshop = TOTAL: $______
TOTAL FEE: $______
Please charge my: MC__VISA__ CARD #________________________
EXP. DATE_________SIGNATURE____________________________

Mail with your non-refundable check to Community Program Innovations, Inc., 34 Castle View Dr , Gloucester MA 01930. Payment must accompany registration form.

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