Certification Conference in Managing Workplace Conflict

Registration Form

Print this webpage, then fax or mail the completed form to MTI. Or, copy and paste the contents of this page into an email or a plain text document (*.txt), then type in the required information. See other ways to register.

Mediation Training Institute
5700 West 79th Street
Prairie Village KS 66208-4604
USA
 Karin Houck, Registrar
Phone:   (913) 338-1113
Toll-free:   (877) 338-1113
Fax:   (913) 273-1919
E-mail:   registrar@mediationworks.com

Person who will be attending:   (If faxed or mailed, please type or print this information very legibly. If multiple registration, use a separate registration form for each person.)

Name/Title:________________________________
Organization:_______________________________
Address 1:__________________________________
Address 2:__________________________________
City/state/province/postcode:______________________________
Country:______________
Phone: (_______)__________________ E-mail:____________________
   Phone required in case of need to clarify registration details.
   E-mail required to receive confirmation letter.

Conference city and date: ______________________________   View schedule

Please tell us how you first learned of this program:__________________
(E.g., search engine, colleague/friend, previous participant, link from other website, National Mediation, other? . . . please describe)

Registration option:   Review registration options and fees.
Indicate which one of the three registration options you select by entering the appropriate registration fee.

Track 1: Trainer Certification

Track 2: Managers

Track 2a: Non-supervisory

Track 3: Professionals

Track 4: Refresher

Track 5: Invitational 		$____________

$____________

$____________

$____________

$____________

CCA#, if any*: _______________

TOTAL due with this registration form: ___________US dollars.

Payment options:
     ____Company purchase order number: _______ (attach company P.O. form)
     ____Check or money order mailed with this form.
     ____Visa/MC/AmEx: (If faxed or mailed, please print this information very legibly.)

          Name as shown on card: ________________________

          Visa   __________ - _________ - __________ - __________

          MC   __________ - _________ - __________ - __________

          AmEx   __________ - _________ - __________ - __________

          Expiration Date: _________/_________/__________ (required)

          Verification Code___________ (required)

          Signature (if faxed or mailed) ________________________________

Class size is limited. Your place in the conference is reserved by full payment.

Refund Policy:
Cancellations will be refunded, less a $100 administrative fee, until two weeks prior to conference date. No refunds within two weeks of conference date.  Persons who cancel less than two weeks before conference date may transfer their registration to a later conference upon payment of a $100 rescheduling fee.  Request for rescheduling must be received within 30 days following original conference date.

* CCA#'s apply to registration for Track 1, 2, or 3 only, and only to Conferences held in the United States. CCA#'s may not be combined with any other discounts. CCA#'s must be provided at the time of initial registration, and may not be applied retroactively.)