EMDR Level I Registration Form

Name:______________________________________________

I have a Masters Degree   [EMDRIA Requirement]    Yes       No

Please attach a photocopy of your Masters Degree

License Number: ___________   Association: _______________ 

Address:  _________________________________________     

Phone: ______________ Fax: _____________ e-mail: ________________ 

Please Indicate Desired Location: 

Fall 2005:
Expanded Program Now With Three Practicums! (12 hrs of Practice!!)

Oct 27-30 Barrie

2006:
Expanded Program Now With Three Practicums! (12 hrs of practice!!)

Feb 9-12  Ottawa CANCELLED

March 23-26 Toronto

Fees:  
Toronto, Ottawa, Stratford $700 + $49.00 GST
*(offer subject to change without notice)

Cancellation Policy There is a $50 cancellation fee any time up to 30 days before a workshop starts. The cancellation fee is $100 if cancellation notice is received with less than 30 days notice.  You may transfer your registration fee at no cost to an alternative workshop offered by Fraser Counselling, if space is available.

Toronto & Stratford Only: Free Bonus with Early Registration:  If you are on of the first 20 participants who register and pay 30 days before each workshop, you will receive a copy of Francine Shapiro's text FREE ($80 value!)

Make cheque payable to:    Susan Fraser  

Pay by:  Cheque      Visa  Visa # ___________________  
                                    Expiry ___/______

Name_____________________Signature_________________________

fax or mail to: Fraser Counselling Services               
For More About This or Future workshops Contact Us: