Registration Form - Parents as Teachers by huanghengdong


									                              Foundational Training and Model Implementation 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, state, zip+4                                                                         Affiliate Code
Supervisor's name                                                                          Supervisor's PAT ID#
Supervisor's email                                                                         Events #                                             9708
If a new supervisor with an existing Affiliate does not yet have a PAT ID#, please contact                  

Date(s) of Training       August 8, 2011          -      August 12, 2011            No registrations will be accepted after:                      July 22, 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?
What is your role in your organization?
Parent Educator (direct service to families)                                    Supervisor (no direct service to families)
                                                                                Supervisor / Educator (direct service to families)
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 section for Office Use Only

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

    Check #                                  Ck Amt: $                      -          last 4#                            Name:

        10/5/2011 4:09 PM                                                                                                                        revised October 2010
           PAYMENT OPTIONS - Please complete this form fully and submit with your registration(s)
                            Foundational Training and Model Implementation
                 Parents as Teachers National Office, 2228 Ball Drive, St Louis MO 63146
 Date Attending                                  Name(s) of Participant(s)                               Fee - $795.00 ea.
        8/8/11                                                                                           $          795.00

                                                                                                         $                 -

                                                                                                         $                 -

                                                                                                         $                 -

                                                                                                         $                 -

       July 20, 2011   to        July 22, 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                                 $         795.00

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 #           9708
           Parents as Teachers                      Telephone          314-432-4330                      Affiliate Code:
              2228 Ball Drive                          Fax             314-983-9520
           St. Louis, MO 63146                         Fax             314-995-3905                            10/5/11 4:09 PM
        10/5/2011 4:09 PM                                                                                        revised October 2010

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