MPC  Course Registration Form 

Name: ____________________________________________

Address:__________________________________________

  _________________________________________________

Occupation:_______________________________________

Phone:____________________________________________

E-mail:____________________________________________

MPC Member Status:  

Member _____      Non-member  _____     Candidate  _____

List courses by name and term:

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________________________________________________________________________

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Send form with a check payable to 'Michigan Psychoanalytic Council' to:  

Full payment is due by the second class meeting unless prior arrangements have been made with the Registrar. 

Acceptance of students for specific courses will be based on previous education and the decision of the course instructor and the Training and Certification Committee.