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Game Therapy Workshop

 July 12-16, 2010

On-line registration is not available. Please print, complete and mail or fax this form as indicated below. Payment may be made by check, purchase order or credit card.

Billing Address

Name ________________________________________

Address ______________________________________

City ____________________  St. ____  Zip _________

E-mail ___________________________

Shipping Address  (__ same as billing address)

Name ________________________________________

Address ______________________________________

City ____________________  St. ____  Zip _________

Game Selection (Check up to 3 for immediate delivery; you may defer the selection of 1,2

or all 3 games until after the workshop if you prefer.)

__ Anger Control __ Bullying __ Changing Family

 __ Drugs & Alcohol __ Family Living __ Feelings

__ Self-Concept __ Self-Control

__ Social Conflict __ Social Skills

Professional work setting

__ school  __ hospital/clinic  __private practice

__ academic __ other

Profession

__ mental health counselor  __ school guidance counselor

__ school psychologist __ social worker  __ psychologist

 __ psychiatrist  __ psychiatric nurse  __ other___________________

__  postcard enclosure with CTS or WPS order 

 __ CTS or WPS website or catalog  __ referred by ____________________________________

 __ NASW News __ NASW website

Lodging. Please indicate whether plan to book a room at __ Captain's Quarters  or __ other

CE Credit Request?

__ No  __ Yes (requires signing in and out for each session. Partial credit is not available)

Method of Payment

 Amount ($490) $___________ (10% discount for 2 or more registrants submitting this registration form at the same time)

__ Check payable to Berthold Berg, PhD

__ Purchase Order attached (or to be mailed by ______________________________________)

__ MasterCard  __ Visa  __ American Express 

__ Discover

Name on card ___________________________

Card # ________________________________

Exp. date _________ (month)  ______ (year)

Billing Address __________________________(Street)

__________________ (City) ______ (St) _________ (Zip)

_________________________________________ (Signature)

Mail to: Berthold Berg, PhD • 1593 Big Hill RD • Dayton, OH • 45429-1206

Fax to: (916)-675-7163

Refunds. Tuition will be refunded (less a $25 administrative fee) for cancellations on or before June 15, 2009. A $35 fee will be charged for cancellations after June 15. Salable games ordered at the time of registration must be returned by mail, along with a note indicating your tuition refund request. Unreturned games will incur a reduction in the refund @ $50 per game.

For questions, e-mail Dr. Berg at berthold.berg@gmail.com