sign-In Forms for CEs - Human Super Power of Attachment LPCAGA

Sign-In Form - for CEs

Please complete and submit at beginning of training to document your participation
Name As You Would Like To See It On Your Certificate *
Your License Number and Type
Date of Registration

Year Month Day
Date
Email *
example@example.com
Phone Number *

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Select Date for Registration *
LPCA-GA APPROVAL #2022-05-15-985MLW. Visit LPCAGa.org for more info.

Approved for 6 CE Core Hours Under NBCC Approved Provider #6920 AD Advantage Counseling & Education Services, LLC
We are a 501(c)(3) nonprofit that provides training and professional development and also promotes public awareness about childhood learning, growth, and development. To that end, we ask permission to record training sessions to use to share with other professionals, parents, and stakeholders in the lives of children with special needs and to promote public awareness of developmentally appropriate practice.
Type a question
LPCAGA or NBCC
May we record this training?

Yes, you can record and use my video for training and public awareness. Yes, you can record but please do not share my image in any public training or public awareness media. No, please do not record me in this training.
If "Other" above, please explain
Should be Empty:

Sign-In Form - for CEs