Register - Parents as Teachers

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					                                                     Foundational Training Registration Form
                                                      When typing use your tab button to move to the next fillable cell

Name                                                                                      SSN# (last 4 digits)
Home address                                                                              Phone (cell / home)
City, state, zip+4                                                                        Email (primary)
Program name                                                                              Office phone
Office address                                                                            Fax number
City                                                                                      Event #                                             9398
State                                      zip + 4                                        Affiliate Code

Date(s) of Training       June 27, 2011          -         June 29, 2011           No registrations will be accepted after:                    June 10, 2011
Location of training                        Parents as Teachers National Office, 2228 Ball Drive, St Louis MO 63146
Have you ever attended any Parents as Teachers training?                          Yes         No        If yes, under what name?

In what context will you be providing family support and parenting education?

1   Briefly describe your supervised experience working with children birth to kindergarten (include # of years):

Check the highest level of education you have completed and enter your field of study in the space provided:

    less than Associates                Associates-Field                                           Bachelors - Field

    Masters - Field                                                            Beyond Masters - Field

 2 Is English your first language?                   yes           no          If no, Primary language:

    By checking this box I agree that I have read and will comply with the terms put forth in the Ethical Agreement.

Submit your registration packet one of two ways:                   Email              Fax 314-983-9520 or 314-995-3905
Do not assume you are registered or make any travel arrangements until you receive verbal or written confirmation. Confirmation packets are emailed within 2
weeks of training.

For questions regarding on-site information and lodging,        contact                Lisa Rivers at or 314-432-4330 x 264

Cancellation Policy: Parents as Teachers reserves the right to limit enrollment or cancel a training in the event of insufficient registrations. Participants may cancel
their registration and receive a 90% refund prior to the first day of training or receive full credit to attend another training.

                                                No refunds will be given after the training begins.
                                                                The gray section for Office Use Only

    P.O. #                                  P.O. Amt: $                    -              Mastercard                      Visa   Amt: $                  -

    Check #                                 Ck Amt:        $               -          last 4#
       PAYMENT OPTIONS - Please complete this form fully and submit with your registration(s)
                                        Foundational Training
                Parents as Teachers National Office, 2228 Ball Drive, St Louis MO 63146
 Date Attending                                  Name(s) of Participant(s)                               Fee - $695.00 ea.
                                                                                                         $                 -
                                                                                                         $                 -
                                                                                                         $                 -
                                                                                                         $                 -
                                                                                                         $                 -

       June 8, 2011    to        June 10, 2011         add $75.00 late fee for each participant          $                 -

 Submitting P.O.                             add a $25.00 processing fee for all purchase orders         $                 -
                 (payment must be US dollars)          Total Payment Due                                 $             -
P.O./Check Information: there will be a $25.00 processing fee for each purchase order-please attach P.O. copy

Affiliate/Program Name:                                                           Affiliate Code

Party responsible for payment:

Billing address:

City                                                              State:              Zip code/Postal:

Telephone number:                                                 Country:

Email Address:

P.O. Number:                                                         Total dollar amount of P.O.

Check Number:                                                      Total dollar amount of Check.

Credit Card Billing Information

Please Check one: Mastercard                 Visa               Payment amount on credit card:

Cardholder name:

Email Address:

Credit Card Number                     ─                ─                  ─                Expiration date:

Billing address for card

City                                                              State:              Zip code/Postal:

Telephone number:                                                 Country:

                                   IF PAYING BY CHECK PLEASE MAKE CHECK PAYABLE TO:
                                                      Parents as Teachers
             MAIL CHECK TO:                         Federal ID#      43 - 1569124                            EVENT #           9398
           Parents as Teachers                      Telephone        314-432-4330
              2228 Ball Drive                          Fax           314-983-9520
           St. Louis, MO 63146                         Fax           314-995-3905