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Register - Parents as Teachers


									                Foundational Training Registration Form for certified Parent Educators/Supervisors
                                                      When typing use your tab button to move to the next fillable cell

Name                                                                                      PAT ID #
Home address                                                                              Phone (cell / home)
City, state, zip+4                                                                        Email (primary)
Program name                                                                              Office phone
Office address                                                                            Fax number
City                                                                                      Event #                                             9445
State                                      zip + 4                                        Affiliate Code

Date(s) of Training     January 31, 2011         -     February 2, 2011            No registrations will be accepted after:                  January 14, 2011
Location of training                        Cornelia Elementary School, 375 Old Cleveland Road, Cornelia GA 30531
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                         Carol James at 706-778-3100 or

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
                Cornelia Elementary School, 375 Old Cleveland Road, Cornelia GA 30531
 Date Attending                                Name(s) of Participant(s)                              Fee - $125.00 ea.
                                                                                                      $                 -
                                                                                                      $                 -
                                                                                                      $                 -
                                                                                                      $                 -
                                                                                                      $                 -

  January 12, 2011     to   January 14, 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 #           9445
          Parents as Teachers                    Telephone          314-432-4330
             2228 Ball Drive                        Fax             314-983-9520
          St. Louis, MO 63146                       Fax             314-995-3905

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