THIS IS NOT AN ONLINE REGISTRATION FORM - FOR PRINT ONLY
Printed Date: 4/17/2024 2:26:27 PM
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Seminar Title: |
5-Day Retreat: Attachment-Centered Play Therapy in a Retreat Setting |
Seminar Date: |
Monday, September 21, 2020 |
Seminar Location: |
PACIFIC GROVE, CA 93950 |
Seminar ID: |
77572 |
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Required (select one) |
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Registration:
$799.00 Advance price by 4/22/20
$899.00 Standard price
Note: Registration does not include sleeping rooms. Use the link below to gain access to our discounted room rates.
Sleeping Room Reservations:
Room rates are per person, per night & includes meals.
$300.15 Single Room
$202.94 Double Room (per person)
For the discounted room rate, reservations MUST be made directly through Asilomar’s registration link below. Phone reservations will not have access to these reduced rates. 4 nights required.
https://book.passkey.com/e/50001939
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________ HI, NM attendees add applicable sales and local taxes**
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________ Subtotal (Required items + sales tax)
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Optional |
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________ AL, AR, AZ, CA, CO, CT, DC, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, NC, ND, NE, NJ, NM, NV, NY, OH, OK, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY attendees add applicable sales and local taxes**
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________ Subtotal (Magazines + Optional items + sales tax)
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________ Total (Required subtotal + Optional subtotal)
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** Tax-exempt customers please send a copy of your tax-exempt certificate.
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*** Registration for coordinator or military member discount must be completed online
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**** All prices are shown in US Dollars ****
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Please enter the MAIL CODE in the box below.
If you have a brochure, this code is found on the back in the box above the address block.
If you do not have a brochure, please enter 888.
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Mail Code or VIP #: |
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First Name: |
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Last Name:
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Profession: |
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Note: Leave Company/Department blank if providing home address |
Company Name: |
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Department: |
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Address: |
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City: |
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State: *
Zip: *
County: *
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Work Phone: |
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Cell Phone:
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Fax Number:
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Email Address: |
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License Number: *
(required for confirmation of registration)
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Prepayment is REQUIRED |
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Check enclosed
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Signed Purchase Order enclosed
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Credit Card Type: |
Mastercard
Visa
Amex
Discover
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Credit Card #: |
V-Code #*
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Exp Date: |
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*MC/Visa/Discover: last 3-digit # on signature panel on back of card |
*American Express: 4-digit # above account # on face of card |
Name on Card: |
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Mail or Fax to:
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PESI Rehab, P.O. Box 1000, Eau Claire, WI 54702-1000 (800) 554-9775 (fax number) |