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