Gestalt Associates Training, Seattle Registration

Seattle Registration - Step 1 of 2

Course Selection(s)

Please select the course(s) you would like to register for: (Only open to participants who have previously attended a Resnick Couples workshop in Seattle or elsewhere.)


Course - A Couple of Individuals - Remaining two workshops: October 9-10, November 6-7, 2010 (FEES ARE FOR BOTH WORKSHOP)	Deposit	Full Fee
Full Registration	$400	$800
Group Registering together - 5 or more (each)	$300	$600
Full Time Students	$300	$600
Student Group Registering together- 5 or more (each)	$250	$500
Volunteer Model Couples needed (2-4)	$100	$200

Participant Information - required fields are in bold

Name
Address Line 1
Address Line 2
City
State/Province
Zip/Postal Code
Country
Work Phone
Mobile Phone
Home Phone
Fax
Email
Highest Relevant Degree
Occupation
Please indicate if you would like CE Credit
If yes, please provide license name and number
How did you hear about this program?

COMPLETE THIS SECTION ONLY IF YOU ARE APPLYING FOR THE ONGOING GESTALT AND/OR COUPLES THERAPY TRAINING PROGRAMS AND ARE NOT KNOWN TO BOB, RITA OR TODD
Current Position and Work Setting:

Previous Gestalt therapy training, including when, how long and with whom:
Previous Couples Therapy training, including when, how long and with whom:
Non-Gestalt therapy training, including when, how long and with whom:

Personal psychotherapy, including when, how long, with whom and psychotherapeutic orientation (optional):

Persons attending this workshop for the first time, please provide 3 professional references including name, address, phone, fax and e-mail. These should be people who know your work as well as people who know you personally.:

Professional Reference #1:
Professional Reference #2:
Professional Reference #3:

Check here if paying by check. Make check payable to and mail to: GATLA 1460 Seventh Street, Suite 300 Santa Monica, CA 90401