Registration Form

 _____________________       _________________________

Last Name                               First Name

 ____________________________________________________________

Address

 __________________________      ____________________________

Home Phone                                     Cell Phone (if applicable)

 Will you be paying the   _____ $850 for certification alone – or-

                                      _____ $1785 to include 3 hours of graduate credit

 I will need CMEs _________ Yes ___________ No

 My deposit check in the amount of $400 is enclosed made payable to the Center for Spiritual Care.

Signature ________________________________ Date ________________

Please print this form and mail with your check to the Center for Spiritual Care, 1550 24^th St., Vero Beach, FL 32960. Space will be limited to facilitate the best learning experience so you will want to register early.