First name: _________________ Last name:____________________

Email address: ___________________________________________

Street address: _____________________________ Apt. #: _______

City: _____________________ State: ___________ Zip: _________

Home phone: ________________ Work phone: ________________


Payment:: Check ____ Money order _____

To pay with credit card, we use Paypal

Mental Health Therapists Workshops		Registered Nurses Workshops	General Public Workshops
36-credit-hour
	$580	$515	$925
15-credit-hour
	$240

Course tuition must be paid in full at least fourteen (14) days prior to first day of class.

Refund policy
Your place in class is reserved immediately upon receipt of payment in our office. Students who have paid tuition in full but must initiate an emergency withdrawal must notify Robert DeMotte Workshops in writing no less than ten (10) days before class begins in order to obtain a full refund less a $45.00 registration set up fee. Students who withdraw within the first four (4) hours in the first class will receive a 50% refund. All materials must be returned in excellent condition upon withdrawal unless student requests to purchase items. No other refunds apply.