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Name: |
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Organization: |
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Address: |
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City: |
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Phone #
Cell Phone # |
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Email address: |
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Prior Training:
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Beginning Level Training in
the Psychological Treatment of Children with Trauma-Attachment Problems Advanced Level Training in
the Psychological Treatment of Children with Trauma-Attachment Problems Dyadic Developmental
Psychotherapy Certification Other (please specify)
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Would you like to present a topic? If so please provide title. |
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Fee: TBA |
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Checks should be payable to Daniel A. Hughes, Ph.D. and mailed to the address listed below:
Quittie Glen Center for Mental
Health 417 Reigert’s Lane
. Annville, Pennsylvania 17003 Mail your completed form and enclose a check or money order for the full amount. For international registration, the check must be drawn from a US bank. If you have any questions please email cday@quittieglen.com or call 717-867-8335. If paying by: Visa, MasterCard or Discover you are welcome to call Monday – Friday 7:00 am – 3:00 pm eastern time call 717-867-8335 or you may email your attached registration form along with your credit card information to: cday@quittieglen.com please include the following information: |
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Name as it appears on the
card: |
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Credit Card Number: |
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Expiration Date: |
Zip Code of the billing
address for the card: |
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3 Digit Security Code: |
Cancellation and refund policy: To receive a refund less
$25.00 service fee, notification must be made no later than April 1,
2013.
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If you wish to share a ride
we will make every attempt to provide contact information of others that are
flying in at around the same time.
Please email Chris Day, Office Manager at cday@quittieglen.com. Please
include the following information: Airport: Airline: Flight arrival time: Email: Telephone number: Comments: |
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