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Applied Psychology
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Continuing Ed
Training for Group Instruction Registration Form
Please complete and mail this form to:
Shelley Viles
Director of Continuing Education
Department of Applied Psychology
Antioch University New England
40 Avon Street
Keene, NH 03431-3552
Training for Group Instruction in the Social Use of Language
Thursday April 16, Wednesday May 6, and Tuesday May 12, 2009
First Name:_____________________________________________________________________ Last Name:______________________________________________________________________ Occupation:_____________________________________________________________________ Company Name:___________________________________________________________________ Mailing Address:________________________________________________________________ City/State/Zip:_________________________________________________________________ Day Phone Number:__________________________________ Evening Phone Number:______________________________ Email:_____________________________________________
Fees
Professional fee: $439
Discount rate per person for family members of an individual with a social communication deficit: $379
Late registration fee, within 14 days of the event: $469
Checks and purchase orders accepted. Antioch Tax ID #310536640.
Checks should be made payable to Antioch University New England.
Check enclosed $_______________ Purchase order enclosed $_______________
© 2007 Antioch University New England, 40 Avon Street, Keene, NH 03431-3516 800.553.8920