Facilitator Workshop Tucker, GA 10/04/2017

Authorized Facilitator Workshop Registration and Payment
* required information
  
 
Please complete the form below. Birth date is a required field for the prerequisite background check. If you are not working with an organization, select Independent as the Facilitator Affiliation.

Your registration will not be complete until you also submit your payment information.

Additional Languages Spoken: Spanish
French
German
Italian
YMCA Affiiliation:
SS Number for Background Check:*
Title:
Workshop Date:(mm/dd/yyyy)
First Name:*
Middle Name:*
Last Name:*
Birth Date:*(mm/dd/yyyy)
Phone:
Preferred Email:*
Organization Name:
Facilitator Affiliation:*
Job Title:
Address Line 1:*
Address Line 2:
City:*
State:*
ZIP/Postal Code:*
Country:*
How did you hear about us?:
Create Username and Password
Username:*
Password:*
Verify password:*
Security Question:*
Security Answer:*



Fees

Fees may include a registration late fee.
$450.00 Registration
Location: DeKalb Family Protection Center, 1950 W. Exchange Place, Tucker, GA 30084.


Discount

If you have received a discount code, please enter it here:

Please proceed to the payment screen to complete your registration.