REGISTRATION FORM

Register early!!

To get the Early Bird Rate we must receive your payment:

BEFORE September 15^th:  $90 per workshop.

AFTER September 15^th,  the Full Rate will apply: $100 per workshop

Deadline for registration or withdrawal (with refund) is: September 30^th, 2008.

After this date, we will only accept a substitute participant if you are unable to attend.

Delicious lunch is included in the cost of registration!

Please complete with your personal or employment contact information:

Name_______________________________________

Telephone No. ______________________ Email________________________________________

Address ___________________________________________________________________________

Employment Agency ________________________________________________________________

 Please check your selection(s):

• Compassion Fatigue
• Grief & Loss
• Safe Talk
• EQ Coaching
• Dinner: $5.00 per person / evening
• Overnight accommodation, including breakfast: $30.00 / person / night

Please indicate amount of payment enclosed with registration:  $_______

Preferred method of payment:

• Cheque
• Credit Card:

                  Type (Visa, Mastercard only):_______________________

                  Card Number:____________________________________

                  Cardholder Name: ________________________________

                  Expiry Date: _____________________________________

Signature: _______________________________________

Complete the form & mail, fax or e-mail to:                Call: 613-259-9114;  Toll Free: 1-888-461-9254

Divine Mercy Centre & Apostolate                               Fax: 613-259-0204   

R.R.4; #2531 Dalhousie Conc.                                       E-mail: administrator@divinemercycentre.com

Lanark, ON   K0G 1K0                                                    WEB: www.divinemercycentre.com