Clone of Group Registration Form

Payer Name

First Name Last Name

Payer Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Payer Phone Number *

Payer E-mail

Confirmation Email

Company/Work Organization

How did you hear about us? *

Online Search Listserv Facebook Friend or Colleague Mailing Other

Message

Workshop Selection and Payment Information *

Mon & Tues, Feb 24 & 25, 2020 - 14 CEU Workshop: Early Group Registration Fee - CPT for PTSD 2-Day Provider Training in Charleston, SC $ 360.00

Number of Attendees
Item subtotal: $ 0.00

Fri, March 13, 2020 - 6 CEU Workshop: Early Group Registration Fee - Understanding Hoarding Disorder in Columbia, MD $ 110.00

Number of Attendees
Item subtotal: $ 0.00

Thurs & Fri, April 23 & 24, 2020 - 12 CEU Workshop: Early Group Registration Fee - 2-Day Supervisor Training Course in Rockville, MD $ 290.00

Number of Attendees
Item subtotal: $ 0.00

Fri, May 1, 2020 - 7 CEU Workshop: Early Registration Fee - Preventing Mass Violence in Rockville, MD $ 130.00

Number of Attendees
Item subtotal: $ 0.00

Sat, May 16, 2020 - 2 CEU Workshop: Early Registration Fee - Working with LGBTQI Clients - Interactive Online Course $ 35.00

Number of Attendees
Item subtotal: $ 0.00

Sat, May 30, 2020 - 3 CEU Workshop: SafeTALK - Free Suicide Prevention Workshop in Rockville, MD Free

Number of Attendees

Thurs & Fri, Jun 11 & 12, 2020 - 12 CEU Workshop: Early Group Registration Fee - 2-Day DBT Training in Rockville, MD $ 290.00

Number of Attendees
Item subtotal: $ 0.00

Fri, June 26, 2020 - 6 CEU Workshop: Early Early Registration Fee - Tele-mental Health Symposium in Rockville, MD $ 130.00

Number of Attendees
Item subtotal: $ 0.00

Fri, July 10, 2020 - 6 Ethics CEU Workshop: Early Early Registration Fee - Reduce Your Legal Liability in Columbia, MD $ 130.00

Number of Attendees
Item subtotal: $ 0.00

Thurs & Fri, July 23 & 24, 2020 -16 CEU Workshop: Early Registration Fee - 2-Day Trauma and Violence Mini Conference in Rockville, MD $ 305.00

Number of Attendees
Item subtotal: $ 0.00

Sun, Sept 13, 2020 - 3 Ethics CEU Workshop: Early Group Registration Fee - Ethics in a Digital Age $ 52.00

Number of Attendees
Item subtotal: $ 0.00

Fri, Oct 2, 2020 - MORNING SESSION 1/2 Day Registration - 3 Ethics CEU Workshop: Early Registration Fee - NASW Ethics Updates in Columbia, MD $ 55.00

Number of Attendees
Item subtotal: $ 0.00

Fri, Oct 2, 2020 - AFTERNOON SESSION 1/2 Day Registration - 3 Supervision Refresher CEU Workshop: Early Group Registration Fee - Supervision Workshop in Columbia, MD $ 55.00

Number of Attendees
Item subtotal: $ 0.00

Fri, Oct 2, 2020 - FULL DAY Registration - 6 CEU Workshop: Early Registration Fee - 3 Hours Ethics and Supervision - 6 CEUs TOTAL in Columbia, MD $ 99.00

Number of Attendees
Item subtotal: $ 0.00

Fri, Oct 16, 2020 - 6 CEU Workshop: Early Registration Fee - CBT for Insomnia in Rockville, MD $ 130.00

Number of Attendees
Item subtotal: $ 0.00

Fri, Nov 13, 2020 - 6 CEU Workshop: Early Registration Fee - Motivational Interviewing in Columbia, MD $ 130.00

Number of Attendees
Item subtotal: $ 0.00

Enter coupon

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Enter the message as it's shown. If message does not appear, click on blue button to the right of the text box. *