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Register - Parents as Teachers

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					                               Model Implementation Training Registration Form for Supervisors
                                                      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 #                                            9385
State                                     Zip + 4                                          Affiliate Code
Date(s) of Training       April 14, 2011         -         April 15, 2011           No registrations will be accepted after:                  March 25, 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 314-432-4330 x 264 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 area 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)
                 Model Implementation Training Registration Form for Supervisors
              Parents as Teachers National Office, 2228 Ball Drive, St Louis MO 63146
 Date Attending                               Name(s) of Participant(s)                              Fee - $200.00 ea.
                                                                                                     $                 -

                                                                                                     $                 -

                                                                                                     $                 -

                                                                                                     $                 -

                                                                                                     $                 -

   March 23, 2011      to    March 25, 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 #           9385
         Parents as Teachers                    Telephone          314-432-4330
           2228 Ball Drive                         Fax             314-983-9520
St. Louis, MO 63146   Fax   314-995-3905