Fax/Mail Registration Form 2012
Courses
June 18-22, 2012	[  ] Spira	[  ] Ferentz
June 25-29, 2012	[  ] Fosha	[  ] Levine	[  ] Seashores
July 2-6, 2012	[  ] Greene	[  ] Ogden	[  ] Funk
July 9-13, 2012	[  ] van der Kolk	[  ] Worley	[  ] Hendrix
July 16-20, 2012	[  ] Schwartz	[  ] McCloskey
July 23-27, 2012	[  ] Axelrod/Diamond	[  ] Wehrenberg	[  ] Boyatzis
July 30-August 3, 2012	[  ] Weintraub	[  ] Wilson	[  ] Zur
August 6-10, 2012	[  ] Katz	[  ] Hallowell	[  ] Wheatley
August 13-17, 2012	[  ] Jellison	[  ] Frederick	[  ] Wagner
August 20-24, 2012	[  ] Korn	[  ] Goldberg
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		$599 U.S. ($549 prior to March 1)
For each additional course		$450 U.S.
Resident physicians/fulltime graduate students		$499 Register by post and include documentation
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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