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REGISTRATION FORM - FAMILY MEDIATION: Theory and Practice

   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.

Please enroll me in the following Family Mediation Program:

Date of program__________________ City ___________________

Full 9-day program

Days 3-9 only*

Domestic Violence only

   I am enclosing a cheque made payable to Dr. Barbara Landau in the amount of:

Full 9-day program $2,396.80 (including GST)

Days 3-9 only $1,893.90 (including GST) *I have previously completed an ADR program

Domestic Violence only $588.50 (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 withdrawl up to 14 days prior to course start date.

   Name : ________________________________ Occupation: _______________________________

   Address:__________________________________________________________________________

   City: _______________________ Province:_________________ Postal: _____________________

   Home Phone: __________________ Bus. Phone:__________________Fax: _________________



   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


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