THIS IS NOT AN ONLINE REGISTRATION FORM - FOR PRINT ONLY            Printed Date: 1/18/2017 8:05:57 AM

Seminar Title:
2-Day: Trauma Conference: The Body Keeps Score-Trauma Healing with Bessel van der Kolk, MD
Seminar Date:
Thursday, April 6, 2017
Seminar Location:
SAN FRANCISCO, CA 94109
Seminar ID:
50635

  Required (select one)
 
$429.99 Single Registration
$389.99 Single Registration: Advance Price (end 3/17/2017)
$389.99 2+ Group Rate: per person
$379.99 5+ Group Rate: per person
$215.00 Student
  ________ HI, NM attendees add applicable sales and local taxes**
  ________ Subtotal (Required items + sales tax)
 
  Optional
 
$23.99 101 Trauma-Informed Interventions: Activities, Exercises and Assignments to Move the Client and Therapy Forward
$23.99 Mindfulness Skills Workbook
$23.99 Mindfulness Skills for Kids & Teens
$13.59 Growing Mindful Card Deck
$47.99 Trauma and Attachment 022712
$47.99 Developmental Trauma Disorder 062210
$47.99 Neuroscience and Trauma Therapy 112210
$159.99 Trauma, Attachment & Neuroscience with Bessel A. van der Kolk, M.D.: Brain, Mind & Body in the Healing of Trauma 042216
$159.99 Shame and Self-Loathing in the Treatment of Trauma 092815
$239.99 2-Day: Trauma Conference: The Body Keeps Score-Trauma Healing with Bessel van der Kolk, MD 120916
$31.99 Trauma Defined: Bessel van der Kolk on The Body Keeps the Score 090214
$239.99 Bessel A. van der Kolk's 26th Annual Trauma Conference: Full 3-Day Conference 052815
$159.99 EMDR: Step by Step: New In-Session Demonstrations 041916
$159.99 Addiction, Trauma, & Adverse Childhood Experiences (ACEs): The Neuroscience behind Developmental/Attachment Trauma and Adverse Childhood Experiences 080116
$14.40 The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma (Paperback)
  ________ AL, AR, AZ, CA, CO, CT, DC, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, NC, ND, NE, NJ,
NM, NV, NY, OH, OK, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY attendees add applicable sales and local taxes**
  ________ Subtotal (Optional items + sales tax)
   
  ________ Total (Required subtotal + Optional subtotal)
  ** Tax-exempt customers please send a copy of your tax-exempt certificate.
  *** All prices are shown in US Dollars ***
 
 

Please enter the MAIL CODE in the box below.

If you have a brochure, this code is found on the
back in the box above the address block.

If you do not have a brochure, please enter 888.

Mailcode Example
Mail Code or VIP #:
*  
First Name:
*   Last Name: *
Profession:
*
  Note: Leave Company/Department blank if providing home address
Company Name:
*
Department:
*
Address:
*
City:
*    State: *    Zip: *    County: *   
Work Phone:
*    Home Phone:   *    Fax Number:  
Email Address:

(required for confirmation of registration)

  Prepayment is REQUIRED
  Check enclosed
  Signed Purchase Order enclosed
Credit Card Type:
Mastercard    Visa    Amex    Discover
Credit Card #:
  V-Code #*
Exp Date:
/ *MC/Visa/Discover: last 3-digit # on signature panel on back of card
*American Express: 4-digit # above account # on face of card
Name on Card:
Mail or Fax to:
PESI, P.O. Box 1000, Eau Claire, WI 54702-1000      (800) 554-9775 (fax number)