MPC Registration Form

Print out the form, shown below, and return it with a $25 non-refundable registration fee for each course to:

Diane Burgermeister, Ph.D
31487 Northwestern Hwy., Ste A
Farmington Hills, Michigan 48334
(248) 855-1695
e-mail: 

Please send one form for each course.

There is an additional $25 late registration fee after August 1, 2006
for each Fall course, and December 1, 2006 for each Winter course.

Course                                                                                                                                       

                                                                                                                                                   

Semester:   [ ] Fall     [ ] Winter        Site:                                                                                

Name                                                                                                                                         

Address                                                                                                                                     

Occupation                                                                                                                                

Phone (Day)                                                                (Evening)                                             

E-mail                                                                 

Membership Status in MPC   [ ] Member     [ ] Request for Membership

Training Program Status in MPC     [ ] Candidate