Workshop Registration Form

Triumphing Over Trauma:  Perspectives from Jung, Culture, Heart Work, and International Trauma Treatment

Saturday, Oct. 13th 2012, 6 CEUs, at Providence St. Peter Hospital Olympia, WA, main building, the 200 Rooms

John Van Eenwyk Ph.D., Heesoon Jun Ph.D. and Steve Macuk, Ph.D.

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Registration Form (Triumphing Over Trauma)

Name__________________________________________________

Degree_______

Company_____________________________________________________________

Address______________________________________________________________

City__________________________________ State__________

Zip______________

Phone (             )_______________________________

Email Address__________________________________________________________

Profession(s).  Please provide your profession and license number(s):

Profession________________________________

License(s)#___________________

*If you are physically challenged and have special needs, please contact Steve Macuk

Registration Fees

$120 Early Registration (Must be received by Sept. 29th 2012) 

$140 Regular Registration (Must be received by Oct. 12th 2012)

$ 160 On-Site Registration (If space is still available)

Discounts

SWABH or Deschutes Psychological Association Members:  Deduct $20

Groups:  Deduct $20 (Three or more registrations received together)

Full-time Mental Health Graduate Students:  Deduct $30 (Proof of status must accompany registration)

Method of Payment

  • Check enclosed made payable to SWABH (Southwest Washington Association of Behavioral Health) 

  • Card (Visa, MasterCard or Discovery Card)

Card #___________________________________________

Exp. date______/______

Cardholder name_____________________________________________________________

Signature ___________________________________________________________________

Mail completed form(s), and check(s) if used,  to:

SWABH, P.O. Box 1303, Olympia WA  98507

Questions:

Phone contact:  Steve Macuk, Ph.D.(360) 292-6080      

Email: stevemacuk@comcast.net