Fax/Mail Registration Form 2018
Courses
June 18-22, 2018 [  ] Plummer [  ] Graham  
June 25-29, 2018 [  ] Johnston [  ] Naiman [  ] Burgess
July 2-6, 2018 [  ] Foxman [  ] Kramer [  ] Frederick
July 9-13, 2018 [  ] Faller [  ] Napier [  ] Forsyth
July 16-20, 2018 [  ] van der Kolk [  ] Dana [  ] McCloskey
July 23-27, 2018 [  ] Wheatley [  ] Curran [  ] Schwartz
July 30-Aug 3, 2018 [  ] Korn [  ] Bush [  ] Prenn/Eldridge
August 6-10, 2018 [  ] Hallowell [  ] Anderson [  ] Meichenbaum
August 13-17, 2018 [  ] Zeig [  ] Piliero [  ] Paquette
August 20-24, 2018 [  ] Akhtar [  ] Fisher  
       
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 $675 U.S. ($625 if prior to March 1, 2018)
For each additional course $525 U.S.
Resident physicians/fulltime graduate students $575 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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