Fax/Mail Registration Form 2010
Courses
June 21-25	[  ] Ortho Symposium	[  ] Schulz
June 28-July 2	[  ] McCloskey	[  ] Ogden
July 5-9	[  ] Cornell	[  ] Bobrow	[  ] Marshak
July 12-16	[  ] Miller/Katz	[  ] Schwartz	[  ] Hallowell
July 19-23	[  ] van der Kolk	[  ] Hendrix	[  ] Greene
July 26-30	[  ] Wagner	[  ] Lapides	[  ] Schein
August 2-6	[  ] Seashore	[  ] Goldberg	[  ] Sestito
August 9-13	[  ] Schwarz	[  ] Allen	[  ] Blaustein
August 16-20	[  ] Fisher	[  ] Magid	full Weintraub
August 23-27	[  ] Korn	[  ] Wheatley
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:		$450 U.S.
Resident physicians/fulltime graduate students:		$495 Register by post and include documentation
Ortho Symposium		$595 ($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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