Program Registration Form

Please print and complete registration form with
mailed check or fax credit card information to:

Rorschach Training Programs

1 Vanderbilt Park, Suite 115

Asheville, NC 28803

or

fax: 828-274-2226

Please Print Legibly

Name: ___________________________________________

Mailing Address:

Street Address ____________________________________

City ______________________________________________

__________________________________________________

__________________________________________________

Billing Address:
(For credit card leave blank if same as mailing address)

Street Address ____________________________________

City ______________________________________________

__________________________________________________

General Participant Requirements (Check One)

_______ Doctoral degree in psychology or related program

_______ Masters degree in psychology or related program

_______ Current student in an APA approved doctoral program

_______ Psychology/testing technician with regular supervision

_______ Psychology Intern

Supervisor Name ___________________________

Supervisor Phone ___________________________

Intern Site _________________________________

_________________________________________________________________________________________________________
City in which Training Program is to be held

Rorschach Training Programs reserves the right to cancel programs with 30 days notice to participants.

No registration refunds will be made within 30 days of the program if a participant cancels.

 Prior to 30 days a participant can cancel his/her registration and receive a refund minus a $50 administration fee.

Payment Information
(No refunds for "no shows")

WE ACCEPT Master Card or Visa ONLY

You will receive a registration confirmation through the mail

______________________________________________
Card Number (required) - Master Card or Visa ONLY

______________________________________________
Card Expiration Date (required)

______________________________________________
Name as it appears on the card (required)

______________________________________________
Authorization signature (required)