Course Registration Form

Course Registration Form
Mark the course(s) that you would like to attend.
Please print and complete fully, one form per attendee.
FAX: 818-728-0944
MAIL: 21601 Vanowen St., Suite 100, Canoga Park, CA 91303

Registration Special for New Attendees - Receive $100 off the 4-Day Neurofeedback in a Clinical Practice course when full payment of 4-Day course fees is received 30 days in advance. This offer is for new 4-Day course attendees only.

O Neurofeedback In a Clinical Practice - Lake Tahoe CA/NV
September 16-19, 2010 • Price: $1095.00 • Reattendee Price: $695
O Neurofeedback in a Clinical Practice - Denver, CO
October 14-17,2010 • Price: $1095 • Reattendee Price: $695
O Neurofeedback in a Clinical Practice - Albuquerque, NM
November 11-14, 2010 • Price: $1095 • Reattendee Price: $695
O Neurofeedback in a Clinical Practice - San Francisco, CA
December 9-12, 2010 • Price: $1095 • Reattendee Price: $695

PLEASE PRINT

Name:

Institution:

Address:

Title/Degree: License #:

Field of Practice:

Home Phone: Business Phone/Ext:

Fax: Email:

How did you hear about our professional Courses? (please include name if referred by an individual)

Course Total: $___________

Credit Card #:_________________________ EXP:____/____/____ 3-digit Code: _____

Signature:______________________________________

Attendees are responsible for their own lodging and meals which are not included in the registration fee. Hotel information will be sent to you upon receipt of registration. Please make your reservations early. Request hotel rates offered for "EEGSpectrum course attendees"; availability and special room rates are subject to limitations.

REFUND POLICY FOR ALL COURSES: If cancellation notification is received at least 30 days prior to the workshop, a non-refundable processing fee of $195.00 is charged. If cancellation notification is received less than 30 days before the workshop, there is no refund of course fees. A qualified substitute may attend in your place if you are unable to attend.

If registration is received less than 10 days prior to course date, manual may not be available at the course.

EEG Spectrum International, Inc. is approved by the American Psychological Association to sponsor continuing education for psychologists. ESII maintains responsibility for this program and its content.

This didactic education program is accredited by BCIA (4-Day Neurofeedback in a Clinical Practice Course Only). Call for details.

EEG Spectrum International, Inc. is an NBCC Approved Continuing Education Provider (ACEP TM) and may offer NBCC approved clock hours for events that meet NBCC requirements. The ACEP solely is responsible for all aspects of the program.

EEG Spectrum International, Inc. is also a CE provider for the California Board of Behavioral Sciences (PCE765); California Board of Registered Nursing (CEP13545); Florida Board of Clinical Social Work, Marriage & Family Therapy and Mental Health Counseling (BAP150); Massachusetts MMCEP 28 contact hours in Category 1 for LMHCs (4-day course); Illinois, Registered Social Workers (159-000889).