Summitry Coaching Registration Form

Please complete registration information below. Check appropriate program for which you wish to register, payment option, and amount enclosed. As appropriate, either enclose check or money order or complete credit card information. For check or money order, mail to: Summitry Coaching c/o PSP, 9912 Business Park Drive, Suite 170, Sacramento, CA 95827 USA. For credit card order, either mail to above address, fax to + 916-364-5511, or e-mail to pattie@psp.edu.

First Name: _________________________

Family/Surname:_________________________

Title (Optional): ______________________

Organization (Optional): _____________________________

Mailing Address: ___________________________________________________________

City: ________________________ State/Province: ______

Postal Code: __________

Country: ___________

E-Mail Address: _­­___________________________________

Telephone Number: _______________________

___________________________________________________________

2006 Program for which You Wish to Register:

_____Washington D.C.- May 17-18, July 22-23 & September 26-27, 2006

_____Chicago (Illinois)- August 23-24, October 21-22 & December 5-6, 2006

_____Harpswell (Maine)- June 21-22, August 12-13 & October 10-11, 2006

______________________________________________________

Payment Option

_________ Option One: $5000 (Total) [$5000 due at registration]

_________ Option Two: $5,500 (Total) [$3000 due at registration/$2500 due at 2nd Workshop]

_________ Option Three: $6000 (Total) [$2000 due at registration/$2000 due at 2nd Workshop/$2000 due at 3rd Workshop]

_____________________________________________________

Payment Method

(Please make payment in U.S. dollars to “The Professional School of Psychology”)

____Check

Check Number: ________________ Amount: US$ __________________

___________Credit Card ______________Visa ___________MasterCard

 Check appropriate card type

Card Number: ______________________________________

Expiration Date(mm/yy): ____________

 

Signature: __________________________________

Name on Card: ________________________________

 

 


    


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