Fax/Mail Registration Form 2008
Courses
June 23-27	[  ] Ortho Symposium	[  ] Schulz
June 30-July 4	[  ] Zur	[  ] Hallowell	[  ] Seashore
July 7-11	[  ] Schein	[  ] Austin	[  ] Bessel van der Kolk
July 14-18	[  ] Schwartz	[  ] Spira	[  ] Bolman
July 21-25	[  ] Korn	[  ] Goldberg	[  ] Levine
July 28 - August 1	[  ] Sachs	[  ] Bien	[  ] Worley
August 4-8	[  ] Schwarz	[  ] Weintraub	[  ] Wagner (Treatment)
August 11-15	[  ] Wagner (Complexities)	[  ] Nelson	[  ] Akhtar
August 18-22	[  ] Newberg	[  ] Potter-Efron	[  ] Josselson
Name and Address
Name:			Degree:
Address:
City:		State:	Zip:
E-mail:		Phone:
Profession:  [  ] HR/OD/Management  [  ] Marriage/Family Therapist  [  ] Counselor  [  ] Psychologist  [  ] Psychiatrist  [  ] Other Physician  [  ] Social Worker  [  ] Nurse  [  ] Other Health Profession  [  ] Other: (please specify)			[  ] Check if you        have previously        attended the        Cape Cod Institute
Tuition
For one course:		$595 U.S.
For each additional course:		$425 U.S.
Resident physicians/fulltime graduate students:		$450  Register by post and include documentation
Ortho Symposium		$495 ($395 for Ortho members)
Payment Method
Check (in US funds):		[  ] payable to Professional Learning Network, LLC
Credit card:		[  ] Visa     [  ] Mastercard      [  ] American Express
Amount to charge to my credit card:		$_______________ US
Credit card number:
Credit card expiration date:		__ __ /__ __    (month/year)
Signature:

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