Registration Form - Dan Hughes, Ph.D.

Clinical Training in the Psychological Treatment of Children with Trauma - Attachment Problems 2012 Training Registration Form
Please Print or Type:
Name:
Address:
City:	State:	Zip code:

Degree:

License (State):

Telephone:

Email:

Agency (if applicable):

Nature of current practice/prior experience and training:

Please select training location and level of training

Beginning Level	July 17-20, 2012	$500.00
Advanced Level	July 23-26, 2012	$500.00

Training Level	Training Dates	Cost
Beginning Level	January 16-19, 2012	$500.00
Advanced Level	April 2-5, 2012	$500.00
Beginning Level	August 7-10, 2012	$500.00
Advanced Level	August 13-16, 2012	$500.00

For Colby College Participants:
Room and board is available for participants for an additional fee which includes four nights with your arrival the day before and meals lunch. The campus gym and swimming poo are available to guests staying on campusl. Meals are very good.

Would you like to reserve a room on campus?

Cost for Room and Board at Colby has yet to be determined but should be about $60.00 per night and that includes meals.

Remember**

Receive your 20% discount on
Developing Attachment: Family Therapy Examples when you register for the beginning level training.

For Annville, Pennsylvania Participants:
Participants are on their own for lodging and meals, however a list of local accommodations will be provided.

Quittie Glen Logo

Registration fee should be payable to:
Daniel A. Hughes, Ph.D.
Send completed application form and payment to:
Dan Hughes, Ph.D.
Quittie Glen Center for Mental Health
417 Reigert's Lane
Annville, Pennsylvania 17003

To pay by credit card please call 717-867-8335 ext. 201 Monday - Friday from 7:00 am - 3:00 pm eastern time. You are welcome to email your registration along with forwarding your credit card information to: Chris Day, Office Manager

** Payment and cancellation policy:
Full payment or an initial deposit of $150.00 is required at the time of registration to reserve a place. The balance is due one month prior to the beginning of the training week. Refunds, minus a $75.00 administration fee are issued up to one month prior to the training date. No refunds will be issued within a month of the training week unless another participant is able to attend minus the $75.00 fee.

Please note: Applicants should have read "Building the Bonds of Attachment, 2nd Edition,"
prior to attending the training program. (click on title to order this book)

Clinical Training in the Psychological Treatment of Children with Trauma - Attachment Problems

2012 Training Registration Form

Clinical Training in the Psychological Treatment
of Children with Trauma - Attachment Problems