Close Window

Print This Form

REGISTRATION FORM - ADVANCED FAMILY MEDIATION

   To register, please enclose a cheque made out to Dr. Barbara Landau. If you prefer to pay by credit card, please indicate account #, expiry date and signature in the space provided.
Tax receipts will be issued.
Please print clearly and keep a copy for your records.


Date of program__________________ City ___________________

   I am enclosing a cheque made payable to Dr. Barbara Landau, in the amount of $1,225.15 (including GST).

   * 5% discount for payment in full received 30 days prior to the course start date.
   * Refunds less $160.00 administration fee for written notice of withdrawal up to 14 days prior to course start date.

Included in your registration fee:
  • Extensive written material and precedents
  • A certificate from Conrad Grebel University College (University of Waterloo)
  • One credit toward a Certificate in Peace and Conflict Studies.

   Name : ________________________________ Occupation: _______________________________

   Address:__________________________________________________________________________

   City: _______________________ Province:_________________ Postal: _____________________

   Home Phone: __________________ Bus. Phone:__________________Fax: _________________

   Prerequisite course:

   Offered by: _____________________________ Date Completed: __________________________



   If payment by VISA Mastercard, please complete:

   Account # _________________________________ Expiry Date: _____/_____/_____ (mm/dd/yy)

   Signature: _____________________________________ Date: ____________________________



   Mail completed form and cheque to:

Dr. Barbara Landau
76 Truman Road
Toronto, Ontario M2L 2L6
Canada



Print This Form

Close Window