Facilitator Training Registration Download

Name
_____________________________

Your Title/Role in Mobilization
_____________________________

Agency Name
_____________________________

Your Mailing Address
______________________________________________

______________________________________________

Office Phone (_____) __________________

Email _________________________________________

REGISTRATION
Check the day for which you are registering. Sessions begin promptly at 9:00 a.m. and conclude at 3:00.

• Wednesday, May 21, 2008 / Location: Littleton, CO

FEE
The cost is $335 for materials, training, teaching rights and lunch.

Total enclosed: $______________. Make checks payable to DualReach.

Credit Card: Visa MasterCard Am. Ex. Discover

Card No. ______________________________________

Expiration Date _________________________________

Name as Shown on Card __________________________

Billing Address for Card (if different from above)
______________________________________________

Please send your registration form and payment via email, fax or mail to:
DualReach, P.O. Box 427, Dana Point, CA 92629
FAX: 949.248.1475
Phone: 949.248.1236

Once your registration and payment are received, you will be sent details about the location of the event and motel options.

How did you hear about this event?
______________________________________________