Download Crossroads Family and Play Institute Name On Card:

Crossroads Family and Play Institute
REGISTRATION FORM
Title of Training: ______________________________________________________________
Date of Training: _________________________
The program offers 3.0 contact hours in Play Therapy. Full attendance is required. Attendance certificate
is provided onsite upon completion. CFPI is approved by the Association for Play Therapy to offer
continuing education specific to play therapy. Provider # 13-360
Cost:
$65.00 Early Bird Registration
$75.00 Regular Registration
$80.00 On Site Registration (space not guaranteed)
*No refunds.*
INSTRUCTIONS FOR REGISTRATION:
1) Print and complete information at the bottom of this form.
2) Pay by check made to the order of Crossroads Family Counseling Center or by Credit Card by emailing
scanned registration form.
3) Option 1: Mail form and check to CFCC, 3611 Chain Bridge Road, Suite C, Fairfax, VA 22030
Option 2: Email form and credit card authorization to [email protected]
_____________________________________________________________________________
Name: _________________________________ ____
Credentials: ____________________________
Address: ____________________________________________________________________________
Street
City
State
Zip
Email: _____________________________________
Phone: ________________________________
Company/Affiliated Agency: ___________________________________________________________
Position: ____________________________________________________________________________
CREDIT CARD AUTHORIZATION
Name On Card: _________________________________________________________
Credit Card (Circle One): VISA
MASTERCARD
AMEX
DISCOVER
Credit Card Number: ______________________________Expiration Date: _________
Security Code (3 digit code in back/4 digit code in front for AMEX): ______________
Billing Zip Code:_________________
Amount to be charged: _________
Signature:_______________________________
Date:______________________
***Upon receipt of your registration, we will send confirmation to your email. Presentation notes
and slides will be sent electronically to your email approximately 1 week before the event.***
***No Refunds***