Parenting With Love Registration Form
Name(s)_______________________________________________
Address_______________________________________________
City__________________________________________________
State_________________________Zip_____________________
Home ( )________________Work ( )__________________
Fax ( )_________________Email_______________________
Referred by___________________________________________
Date of workshop______________________________________
Method of Payment
_ Check
_ Visa/MC/AmEx #______________________________________
Exp. Date__________________________
$ Amount__________________________
Card Signature________________________________________
Make checks payable to Beverly S. Talan, Ph.D.
and mail with this registration form to:
380 N. Old Woodward, Suite 156, Birmingham, MI 48009
Or Fax to: (248) 626-8089
Sign up Soon - Space is Limited!
The registration fee of $175 for individuals or $350
for couples is due one week before the workshop begins.
Cancellation Policy: If you withdraw 8 days or more
prior to the start date of the workshop, your fee will
be refunded, less a $75 administration fee. For
withdrawals made 7 days or less prior to the start of
the workshop, your fee is non-refundable, but can be
transferred to the next workshop.