Michigan Psychoanalytic Council - PCD Registration Form

Print out the form below (one for each course),
and return it with the course fee to:

Jean Wixom, Ph.D., 332 East Washington, Suite B, Ann Arbor, Michigan, 48104, Email: . Phone: (734) 662-7513. Please include the appropriate fee and make checks payable to Michigan Psychoanalytic Council.

Course Title(s): _______________________________________________________________ Fee(s): ____________

Name: _______________________________________________________ E-mail: _____________________________

Address: _________________________________________________________Phone: _________________________

Membership status in MPC ___ Member ____ Request for membership material

Confirmation of registration and forthcoming details regarding classes will be forwarded by e-mail if possible.