2012 Parent Academy Registration Form

BICA Workshops

Registration - Parent Academy

Please submit one online registration per participant.

First Name

Last Name

Organization

Address Type Home Work

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Work Phone

(format xxx-xxx-xxxx)

Home Phone

(format xxx-xxx-xxxx)

FAX
(format xxx-xxx-xxxx)

E-mail

Confirm E-mail:

REFUND POLICY: Refunds will not be given for Parent Academy events. If you are unable to attend, you may send a replacement. In the event of illness or emergency, you may submit a request by email for a voucher to attend a future event or to purchase materials at the BICA Bookstore.

Registration Options

A $10 gift certificate to BICA Bookstore will be given for pre-registration of 3 or more sessions. Space is limited.

Payment Options

USA Funds only please

Payable to Behavioral Institute for Children and Adolescents (FED ID #41-1703237)

Total Fee
	Check	check number: mail with copy of registration form
	Purchase Order	P.O. number: mail/fax with copy of registration form
	Credit/Debit	After you submit your registration using the SUBMIT button below, you will receive a confirmation page with an opportunity to enter your credit/debit card information and activate your registration.