Full Name:
Select One:
Self-employed
Full-time
Part-time
Student
Are you a social worker or a counselor?
Yes
No License #
State
Will we be issuing you a CEU certificate for social work or counseling hours? (11 core)
Yes
No
if so, how would you like your name to appear on your CEU certificate?
Name of your company:
Home or office mailing address:
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ZIP:
City:
Cell phone:
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Work phone:
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Fax:
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E-mail address:
Confirm E-mail address:
Website (if applicable):
How did you hear about this training?
Internet
E-mail
flyer
other
Workshop you are registering for:
08/21/10 & 08/22/10 CLYL training (Sat & Sun)
Bliss Yoga Studio,
Woodstock, GA
10/02/10 & 10/03/10 CLYL training (Sat & Sun)
Santa Rosa Beach, FL, exact locationĀ TBA
10/23/10 & 10/24/10 CLYL training (Sat & Sun)
Winnwood Retirement
Community,
Marietta, GA
Method of payment:
Cash
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Purchase order
Paypal*
Exp date:
Month
Jan
Feb
March
April
May
June
July
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Oct
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Year
2010
2011
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2014
2015
2016
2017
Please call or e-mail us to register for 2 people at once.
Please call Craig at (770) 517-3363 ext 5, or on his cell at: (404) 520-0221.
Please make checks payable to: Blue Skies CCH, INC.
*Please return to trainings page (click the back button once) to pay using Paypal