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Registration Form (print to use)

 

Student_________________________________Grade_____School____________________

Address_______________________________________City_____________ZIP_________

Parent attending with the student_________________________________________________

Home Phone____________________________Work Phone__________________________

Additional student/s from the same family?  If yes:

Student_________________________________Grade_____School____________________

The workshop is offered on Tuesday, Wednesday, and Thursday evenings.  In order to accommodate the largest number of people, please list any nights you cannot come:____________

__________________________________________________________________________

How did you learn about the Workshop?__________________________________________

__________________________________________________________________________

Signing Up: To hold your place in the next workshop, send a non-refundable deposit of $40.00 per student with this registration form.  You will be notified by mail approximately one week before your workshop begins.

 
Mail to:
 
Attn: Jan
Salem Psychology Center
2493 State Street

Salem, OR 97301

 

Tel: (503) 588-1010   jan@salempsychology.com

 

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