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Birth Professional Training Registration FormDate ________________ Contact InformationName
___________________________________________________________ Address
_________________________________________________________ City
____________________ Province ___________ PC __________________ Home
Phone _____________________ Work Phone _____________________ Email
___________________________________________________________ Additional Information (optional)q
Send information on area
accommodations q Yes, I would like to stay on-site at Immanuel's Retreat Center (west of Edmonton, AB) Workshop Choicesq
Childbirth Educator Workshop
q
Nov. 10-12, 2006
at Immanuel's Retreat
Center
$350.00
q
March 2-4, 2007
at Immanuel's Retreat
Center
$350.00
q
Childbirth Doula Workshop
q
Sept. 29-31, 2006
at Immanuel's Retreat
Center
$350.00
q
March 15-17, 2007
at Immanuel's Retreat
Center
$350.00 q Postpartum Doula Workshop
q
Oct. 13-15, 2006
at Immanuel's Retreat
Center
$350.00
q
April 21-23,
2007
at Immanuel's Retreat
Center
$350.00
q
Early Bird Discount,
for
registrations received one month prior to workshop
$ -25.00 Advanced Workshop Choicesq
Advanced Body Awareness Workshop
q
October 28, 2006
at Immanuel's Retreat
Center
$100.00
q
March 24,
2007
at Immanuel's Retreat
Center
$100.00
q
Early Bird Discount,
for registrations received one month prior to workshop $ -8.00
Total
Workshop Fees
_______________ Refund Policya)
If Mother Care receives a written notice of withdrawal before
registration close (two weeks prior to workshop date), Mother Care will retain
the lesser of 10% of the total workshop fees or $50. b)
If Mother Care receives a written notice of withdrawal after registration
close (two weeks prior to workshop date), Mother Care will retain the lesser of
50% of the total workshop fees or $200. c)
Participants are not eligible for refunds after commencement of workshop.
d)
If the workshop is cancelled, participants can either choose to register
for an upcoming Mother Care workshop or apply for reimbursement of paid workshop
fees.
q
I understand and agree with the
above refund policy. Signature
_______________________________________________________ Make cheque or Money Order payable to Connie Banack. Print
this form, complete order and mail with payment to: Mother Care4
Lamplight Bay Spruce
Grove, AB T7X 4N2 Phone/Fax:
780/962-1846
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