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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 email@example.com 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 firstname.lastname@example.org 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
"Register - Parents as Teachers"