Workshop Application

Space is Limited                                                                       Register Early

 

Part I Workshop Dates__________________ Part II Workshop Dates___________________

 

Use ONE registration form for all participants from your agency.  Limit THREE attending per agency, per class.

Individual participant preliminary interviews are required.  A Circle of Ten professionals will call and schedule a 20-minute interview.  This allows Circle of Ten to tailor the workshop to meet the needs of each individual and agency.  All applications must be submitted to the Workshop Committee for approval.

 

AGENCY NAME ______________________________________________________________

 

Address____________________________________________________________________

 

City_________________________State________Zip_____________County____________

 

Phone _(_________)__________________________________Ext._____________________

 

Fax_(_________)____________________________Email____________________________

 

INDIVIDUALS REGISTERED:                                Indicate best time of day to call for interview.

 

1) Name ____________________________Title___________________ Time to call_________

 

Phone_____________________Ext.____Fax_________________Email___________________

 

2)  Name ___________________________Title__________________ _ Time to call_________

 

Phone_____________________Ext.____Fax_________________Email___________________

 

3) Name ___________________________Title____________________ Time to call_________

 

Phone_____________________Ext.____Fax_________________Email___________________

 

WORKSHOP COST:             $ 800 per participant, per workshop.   AMOUNT DUE $_________

Actual per participant cost ($2,000) subsidized by foundations, corporations, banks, individuals and others to lower registration fees.    

Method of Payment - Check One:  ____Check enclosed      Date to be mailed:_______________

 

____Purchase Order # _____________        ___Visa ___ MasterCard   Expiration date: ___/___/__

 

Credit Card Account #__ __ __ __ -__ __ __ __-__ __ __ __-__ __ __ __

 

Name as it appears on credit card: ____________________ Signature ____________________ 

Registration confirmed upon receipt of this form & check, purchase order number, or credit card approval.

Cancellation and Transfer Policy - 22+ days, Full refund less $200 processing fee.  14 – 21 days-Tuition refunded less 50% processing.  Transfer toward future date with 14 days notice-$50 processing fee.   Less than 14 days-Fee forfeited.  ALL requests must be made by letter or fax.

 

Photo/Citation Consent: The undersigned hereby authorizes A Circle of Ten, Inc., it’s employees, authorized agents, affiliates or representatives to: photograph, video/audio tape, use quotes and interviews in print and web based media.

 

Please check all that apply:  Photo: __No Web  ___No Paper ___No Photo     Citation: __No Web  ___No Paper ___No Citation

 

Signature for commitment to attend date(s) listed above:

 

Signature _______________________________                                  Date________________

 

Office Use Only: Date_____________ Participants  ____1  ____2  ____3      Amount Received $_______   Date Received____________ Confirmed_______________________ Sent by_______ Date____________

 

_{Copyright 1996 Holdway & Associates       All Rights Reserved          7/15/03}