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Alliance - GISC

Volunteer Client Registration Form
Group Intensive Training Program 2012

If you are requesting a fee remission (and can verify enrolled student status and/or financial hardship), you must register in person with Gigi Maganja, our Payments Officer, at 440.205.8606. Send your contact info below to osdregistrar@gestaltosd.org along with your reason for this request.

Required fields are marked with an *.

Contact Information
First Name:
Last Name:
Address:
Address Line 2:
City:
State/Province:
Zip/Postal Code:
Country:
Email:
Home Phone:
Work Phone:
Cell Phone:
Fax:
Demographics
Sex:	Female Male
Age:
Session Preferences
AGREEMENT I understand that I may attend one or both weekend client group experiences offered. By completing this form, I agree that I will be present for the full weekend(s) that I choose to attend. The weekend(s) I wish to attend are marked below.
	Friday through Sunday, May 25-27, 2012 Friday through Sunday, August 24-26, 2012
Other Information
I will be arriving with the following people: I was referred to this program by:
Your participation as a client in the Group Intensive Training Program is acknowledged to be a contribution to our students' learning as well as a learning opportunity for you. The client registration fee is set at a nominal $25.00. This fee may be waived for those (particularly college students) demonstrating financial hardship.

GICOSDISC reserves the right to change faculty, program dates, and fees as necessary. GICOSDISC assumes no liability for expenses incurred by participants due to any changes in program dates, including nonrefundable travel and/or lodging expenses.

GIC OSD ISC
Mail: PO Box 1569, Mentor, OH 44061
Phone: 440.205.8606
Fax: 440.205.8606
Email: osdregistrar@gestaltosd.org

Technical problems: webhelp@gestaltosd.org

Volunteer Client Registration Form Group Intensive Training Program 2012

Volunteer Client Registration Form
Group Intensive Training Program 2012