REGISTRATION PAGE


Implementing an Attachment-Based Treatment for Complex Trauma

April 25, 2008

 

Title:
First Name:
Middle Initial:
Last Name:
Home Phone
Work Phone
E-Mail Address
Confirm E-Mail Address
Are you a member of MPA:
Will you be using a MPA Voucher:
Would you like to receive e-mail about upcoming MPA CE programs:
Do you require special accomodations in order to participate:
Do we have permission to print your name/address on the participant contact list, for networking purposely only:
Please enter your degree, if any (eg: Ph.D., M.S., None, etc):

Payment Options:

Registration Fees
MPA Members
$ 155.00
Non MPA Members
$ 205.00

1. You may register online using our secure server (easiest method).

2. A check for the total registration fee may be sent to the MPA Office at: Suite 102, 10025 Governor Warfield Parkway, Columbia, MD 21044. Please indicate on your check for which workshop you are registering. HOWEVER, you must still fill out the top half of this form, print it, and mail it with your check.

3. You may phone the MPA Office (410-992-4258) and register over the phone.

4. Complete this form, to include credit card information, print it, and FAX the entire form to the MPA Office at 410-992-7732.

When entering your Credit Card information please include the billing address that matches your credit card billing address.  Thank you!

Name On Card:
Credit Card Type:
Credit Card Number:
Expiration Date:
Billing Street Address:
Billing City:
Billing State:
Billing Zip:

(Your credit card information is being sent over a secure server.)

Once you submit your registration, you will receive an e-mail confirming that MPA
has received your registration. Following confirmation of your credit card information,
you will receive a confirmation via US Mail, and directions for the workshop. This is
usually sent approximately one week before the workshop date.

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