Use this form to register for Five-hour Workshop for Mental Health Professionals
The Body In Psychotherapy and Psychoanalysis (10am-1pm) and
Change Your Eating Change Your Life (3-5pm)

My Contact Information (please use one form per person)
Name, Degree:    _______________________________________________________

Occupation:         _______________________________________________________

Street Address:   _______________________________________________________

City, State, Zip:   _______________________________________________________

Home Phone:      ____________________Work Phone:   _______________________

Fax:                    ____________________ Email:  _____________________________

Fees
Workshop (includes 5 hours CME/CE for physicians and psychologists or certificate of attendance for other mental health professionals): $125
Donor Reception: Additional $100 tax-deductible donation per person

Form of Payment
I wish to purchase ___ workshop ticket(s) and ___ ticket(s) to donor reception.
Total amount of payment: ____________.
_____ Enclosed check payable to the NC Psychoanalytic Foundation
_____ Credit Card, please check type of card: Visa ___      Mastercard ___

Credit Card Account Number:  _____________________________________________
Expiration Date:  ________________________________________________________

Name (as it appears on credit card):  _________________________________________

Zip Code (of credit card billing address):  ____________________________________

Signature:  _____________________________________________________________

Deadline
To guarantee space at workshop or reception, registration must be received by February 18.  After deadline, call (919) 847-2323 to check space availability. 

Please Mail Form and Check to
North Carolina Psychoanalytic Foundation
7474 Creedmoor Road #107
Raleigh, NC 27613

Space is Limited   Please Register Early