PAY BY CHECK OR MONEY ORDER:

Make check or money order payable to: Education Workers Group

PRINT THIS FORM and mail along with payment to:
Education Workers Group
45 Page Avenue
Staten Island, NY 10309



NAME: (As you want it displayed on your certificate)
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First Name __________________________________________ (required)

Last Name __________________________________________ (required)

Middle Name __________________________________________


ADDRESS: (As you want it displayed on your certificate)
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Address __________________________________________ (required)

Address (line 2) __________________________________________

City __________________________________________ (required)

State __________________________________________ (required)

Country __________________________________________ (required)

Zip/Postal code __________________________________________ (required)


CONTACT INFORMATION:
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Phone __________________________________________ (required)

E-Mail __________________________________________ (required)









LOGIN INFORMATION:
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Choose a unique username and password that you will use to login to the web site.


Username __________________________________________ (required)

Password __________________________________________ (required)



PROFESSION:
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--- Circle Your Profession below ---
Chiropractor - Dental Hygienist - Dentist or Optometrist - Physician - Podiatrist - Psychologist - Registered Nurse - Teacher - Social Worker - Mental Health Counselor - Marriage and Family Therapist - Creative Arts Therapist - Psychoanalyst - Other


CHOOSE YOUR WORKSHOP(S):
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Check the workshop(s) you would like to take and calculate the total at the bottom:


______ $39.95 - Child Abuse Prevention Workshop

______ $44.95 - School Violence Prevention & Intervention Workshop

______ $74.95 - Both Child Abuse Prevention & School Violence Prevention Workshops

______ $49.95 - Needs of Students with Autism Workshop

______ $29.95 - Infection Control Workshop

______ $29.95 - 2 Hour HIV/AIDS Mandated Training (WA)

______ $44.95 - 4 Hour HIV/AIDS Mandated Training (WA)

______ $59.95 - 7 Hour HIV/AIDS Mandated Training (WA)

$ __________
TOTAL



Make check or money order payable to: Education Workers Group

Mail this form and payment to:
Education Workers Group
45 Page Avenue
Staten Island, NY 10309



*** Please allow 2-5 business days for your workshop(s) to be active. If you are sending a personal check, please allow 5-7 business days for your workshop(s) to be active. Once your workshop(s) are ready you will be contacted via email. If you have any further questions please contact us at (718) 608-6000