Fax/Mail Registration Form 2017
Courses
June 19-23, 2017 [  ] Johnston [  ] Kort  
June 26-30, 2017 [  ] Plummer [  ] Graham [  ] Naiman
July 3-7, 2017 [  ] van der Kolk [  ] Frederick [  ] Foxman
July 10-14, 2017 [  ] Faller [  ] Ogden [  ] Joiner/Whitestone
July 17-21, 2017 [  ] Forsyth [  ] Weintraub/Mackay [  ] McCloskey
July 24-28, 2017 [  ] Sachs [  ] Schwartz [  ] Austin
July 31-Aug 4, 2017 [  ] Bush [  ] Porges [  ] Korn
August 7-11, 2017 [  ] Hallowell [  ] Fisher [  ] Schwarz
August 14-18, 2017 [  ] Curran [  ] Zeig [  ] Anderson
August 21-25, 2017 [  ] Paquette [  ] Prenn  
       
Name and Address
Name: Degree:
Address:
City: State: Zip:
E-mail: Phone:

Profession:
 [  ] HR/OD/Management
 [  ] K-12 Teach/Admin/MHpro
 [  ] Marriage/Family Therapist  
 [  ] Counselor
 [  ] Psychologist
 [  ] Psychiatrist

 
 [  ] Other Physician
 [  ] Social Worker
 [  ] Nurse
 [  ] Other Health Profession
 [  ] Other: (please specify)
 
[  ]
 
Check if you have previously attended the Cape Cod Institute
Tuition
For one course $599 U.S.
For each additional course $450 U.S.
Resident physicians/fulltime graduate students $499 Register by post and include documentation
Payment Method
Check (in US funds) [  ] payable to Professional Learning Network, LLC
Credit card [  ] Visa     [  ] Mastercard      [  ] American Express
Amount to charge to my credit card  $_______________ US
Credit card number  
Credit card expiration date __ __ /__ __    (month/year)
Signature  
 
Print this form, then mail or fax it to:
  Cape Cod Institute
Professional Learning Network, LLC
270 Greenwich Avenue
Greenwich, CT 06830
 Fax: 203-629-6048
 Voice: 888-394-9293 (toll-free) or 203-422-0535
 E-mail: registrar@cape.org

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