January 2025 Brain Science Specialty Workshop Registration Form
Deb Antinori, Presenter - January 17 & 31, 2025, 10am-5pm US & Canada Eastern Standard Time
Brain Science to Inform Your BSP Practice: AKA Animal Brain Gone Wild!
(The Unabridged Version)
Name
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First Name
Middle Name
Last Name
Address
*
Street Address
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City
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Postal / Zip Code
E-mail
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example@example.com
Mobile Number
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Format: (000) 000-0000.
Work Number
Format: (000) 000-0000.
Company
License Number:
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Trainings taken and dates:
*
Any neuroscience background?
*
Your Name and professional initials you would like to appear on your Certificate of Completion
*
Ex. Jane Doe, LPC or J. A. Doe, LPC
Please indicate if you are a Grad, and if you are an April 2024 Grad indicate that as "Grad-April 2024", or use code if I have given you one.
Payment of $495 (If paying by credit card, there is a $16 processing fee for the credit card company, so fee goes up to $511 in that case). $50 off for Institute Members with your registration number: RMBI, SEBI, MBI
Please Select
Venmo- @Deborah-Antinori
Zelle- Deborah Antinori, 908-507-4254
Check- Mail to: 1 Harborside Place, Apt 158, Jersey City, NJ 07311
If you have any questions, please contact Deb at dantinori@gmail.com.
Registration number: RMBI, SEBI, MBI
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