Registration Form for the Ethics and Records Keeping Course

Complete the form below to register to this continuous education activity. The fields marked by an asterisk (*) are required.

You can pay by credit card or by check or mail order. Your registration will be confirm once your payment has been received.

For more information on this continuous education activity, please see the page on this subject in the Psychotherapist section.

Total 0

Total	0

Choice of session

Please select the serie of sessions you wish to attend: * 13 septembre et 11 octobre 2013 à Mont-Royal = $250.00 November 8 and December 6, 2013 (location to be determined) = $250.00 15 novembre et 13 décembre 2013 à Mont-Royal = $250.00

Please note that the prices above do not included the GST or the QST. The total cost for both sessions, including both taxes, is $287.44.

Cancellation Fees

All cancellations of a registration will result into a 15% penalty charge. If cancellation occurs less than two (2) weeks before the scheduled date of the activity, the total amount will be charged.

* I have read and understand the cancellation policy.

Attendee

Name *
First name *
E-mail address *

Affiliation

Are you a member of an association of psychotherapists? * Yes No, but I have a bachelor degree in the field of mental health and human relations
		Please select all the associations of psychotherapists you are a member of :
		Association des psychothérapeutes psychanalytiques du Québec
		Société canadienne de psychanalyse
		Société québécoise des psychothérapeutes professionnels
		Other, and I have a bachelor degree in the field mental health and human relations
		Specify: *

To contact you

Telephone at home * (NNN-NNN-NNNN)

Telephone at work (NNN-NNN-NNNN)

Extention

Address

N° *		Street *		Apt./Suite
City *
Province Quebec Alberta British-Columbia Prince-Edward-Island Manitoba New-Brunswick Nova-Scotia Ontario Saskatchewan Newfoundland/Labrador Northwest Territories Yukon
Postal Code * (no space)

Page 1 from 1

Next page