Co Counselling Registration Form |
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| First Name : | __________________________________________ | |
| Last Name : | __________________________________________ | |
| Preferred Name : | __________________________________________ | |
| Address : | __________________________________________ | |
| __________________________________________ | ||
| __________________________________________ | ||
| Phone - home : | __________________________________________ | |
| Phone - work : | __________________________________________ | |
| Email : | __________________________________________ | |
| Occupation : | __________________________________________ | |
| Birthdate : | __________________________________________ | |
| PLEASE REGISTER ME : | I enclose (make cheques payable to Co Counselling) : | |
| - $895 full payment (sliding
scale to $650) Those on lower incomes have the option of sliding down the scale. Payment plans and some subsidised places available. |
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| - $50 deposit | ||
| PLEASE NOTE : | To secure your place on the course you must return your completed registration form and pay the course fee in full. Course registrations must be fully completed 48 hours prior to course commencement. We reserve the right to cancel this course at any time. | |
| SEND TO : | Co counselling, 13 Maidstone Street, Ponsonby, Auckland New Zealand, +64 (9) 376 2386 |