Registration Form

First Name: ______________________________

Last Name:________________________________

Profession:____________________      Prof. Lic#_________________

Address:________________________________________________

City:_________________________________ State:______ Zip:___________

Daytime Phone (   ) ________________      E-Mail_____________________

I wish to register for: (Check all that apply)  Lectures will be held in the Auditorium, La Maison Francaise from 12:30-4:00 PM

____ Leonard A. Doerfler, Ph.D., Friday October 24, 2008

____ Monika E. Kolodziej, Ph.D., Friday, November 21, 2008

Make check payable to: Assumption College and return to: Sue Volungis, Psychology Department, Assumption College, 500 Salisbury Street. Worcester, MA 01609-1296

Licensed Mental Health Counselors:  Assumption College is recognized by the National Board of Certified Counselors to offer continuing education units for LMHCs.  We adhere to NBCC Continuing Education Guidelines:  Provider Number 4009.

Social Workers:  Application has been made to the MA chapter of NASW for CEU'S

I wish to receive CEUS for:

Leonard Doerfler Ph.D.             3 CEU CREDITS
Monika E. Kolodziej, Ph.D.       3 CEU CREDITS

Registration may be faxed to (508) 767-7263 and payment made at the door.  Please call (508) 767-7390 for further information.