If you pay using the PayPal button below, please include this information in the “Notes to seller” section of the PayPal form:: Parent name(s), address, phone, email, children’s names/ages, DSS Agency & social worker. Thank you!You may pay online using the PayPal button above, or, you can print this form out and mail or fax it to us. Thank you!

REGISTRATION FORM

Instructors:  Somer George & April Hepler

Dates:    TBA
Time:     6:30 – 8:30 pm

Location:  The Gathering Place, 841 Mount Clinton Pike, Harrisonburg, VA 22802

Course Fee: $795 per person (In some cases, tuition may be paid by DSS).

PARENT’S NAME: ________________________

ADDRESS: _______________________________

PHONE: _________________________________

E-MAIL (for each parent): __________________

________________________________________

DSS AGENCY & SOCIAL WORKER:

__________________________________________

FIRST NAME(S) and AGES OF CHILDREN:

__________________________________________

__________________________________________

Complete and mail this registration form along with a check payable to:
Virginia Child & Family Attachment Center, 1001 E. Market St., Suite 201, Charlottesville, VA 22902

Or fax the form to: 434-328-2953

A full tuition refund will be given for cancellations made at least two weeks before the start date; a 50% refund will be given for cancellations made through the day before the start date; No refund will be made for no-shows or cancellations the day of the training, however, attendance at a future training will be offered.