MPC Registration Form

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

Patricia Marciniak, M.S.W.
6026 Harkson Drive
East Lansing, Michigan 48823
(517) 332-2006
e-mail: 

Please send one form for each course.

There is an additional $25 late registration fee after August 1, 2004
for each Fall course, and December 1, 2004 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