Cooperative Parenting Institute

COOPERATIVE PARENTING INSTITUTE Parenting Coordination Training Novemeber 2017-Atlanta, GA Registration Form

Please print legibly and neatly. Use your business information as some of the information will be included on your certificate and the on-line directory.

Name: ______(As you would like it to appear on your certificate. Include credentials after your name if you would like them included on your certificate)

Credentials: _____ Masters _____ Specialist _____ JD _____ Doctorate _____ Other Profession: ___ Psychotherapist ___ Social Worker ___ Psychologist ___ Mediator ___ Attorney ___ Judge ___ Other

License & Number (if applicable): ______Address: ______(street) (city/town) (state) (zip code) Business Phone: (______) ______Home Phone: (______) ______Fax: (______) ______E-Mail: ______Print Neatly How did you hear about the training? ___AFCC ___GAMFT ___ CPI Website _____ Google ___Colleague ___Other_____

November 9-11, 2017 Courtyard by Marriott Atlanta, Buckhead 3332 Peachtree Road NE Atlanta, Georgia 30326 678-66-3661 Sleeping rate with CPI is $135

Basic 20 hr Fee: $500 (early bird fee through 10/19/17) Full fee $525*

*For those from NC needing 24 hours -fee is $590 and for those from LA needing 26 hrs-fee $635

______20-hour ______24-Hour ______26-hour

Payment Amount: $______

Payment Method: ______Enclosed is my check or money order payable to CPI ______charge card

Mail check to Susan Boyan @ The Cooperative Parenting Institute 1936-A Northd Druid Hills Road, Brookhaven, Georgia 30319 Or fax this form to 404-982-0006 ____ Charge to my credit card: ______Visa ______MasterCard _____ Am Ex *add $15.00 Credit Card Fee

Card Number ______Security Code ______

Expiration Date ______/______/______Billing Zip Code ______

Print Name of Card Holder ______

Authorized Signature ______

Your Fee Includes: 3 full days of training 3 days of breakfast Certificate of completion Listing on www.parentingcoordinationcentral.com Inclusion on listserv One copy of the Cooperative Parenting and Divorce: A Parent Guide to Effective Co-parenting One copy of the latest revision of the training manual entitled, Parenting Coordination Resource Manual (Formerly Psychotherapist as Parent Coordinator in High-Conflict Divorce.) Tips: 1. Dress for comfort and in layers because the temperature is difficult to keep everyone comfortable.

2. Breakfast and networking 8:00-8:30 am. Lunch on your own 12:30-1:30. Training ends on Thursday and Friday at 5:00 pm and at 4:00 pm on Saturday.

3. To avoid unnecessary parking fees consider taking our MARTA transit system to the center of Buckhead where you will not need a car.

4. If you are coming from the airport take MARTA to the Buckhead/Peachtree station. It is only one short block from the hotel.

5. Please make sure your name and business address are correct and easy to read on the registration form as this is what is used to create your certificate. Be sure to indicate what designation you would like with your name. If your name is short you can fit two otherwise only use one such as Esq. LPC. Etc.