Free 6978 - Indiana

Qualified Mental Retardation Professional Designee Training Registration
State Form 6978 (R7 / 9-98) Form approved by State Board of Accounts,1998

Indiana Protection & Advocacy Services 4701 N. Keystone Ave., Suite 222 Indianapolis, Indiana 46205

INSTRUCTIONS:

1. Please type or print legibly in ink. 2. All areas must be completed for registration. 3. Return to IPAS with payment.

Registration fee is $165.00 per person. Please make all checks and money orders payable to Indiana Protection and Advocacy Services. (SORRY, BUT NO PERSONAL CHECKS ACCEPTED. NO TELEPHONE REGISTRATIONS OR SORRY CCEPTED. REGISTRATIONS SORR BUT RESERVATIONS WILL BE HONORED.) Registration is done on a first paid registration are first registered basis, and once the RESERV HONORED.) class is filled registration for the next class will begin. Registration forms accompanied by registration fee must be in our office seven seven (7) days prior to the training session, provided that space is available. No refunds. However, You may make arrangements to send a substitute or to reschedule if a conflict arises.
Name of Registrant (last, first, middle)

Mailing Address (Facility if any)

Mailing Address ( number and street)

Mailing Address (city)

Mailing Address (state)

Mailing Address (zip code)

Day time telephone with area code

Telephone Fax number with area code if any

Dates of class you are registering for:

Amount of Check

NOTE THIS WARNING AND SIGN
Due to administrative constraints IPAS cannot make refunds. If scheduling conflicts should arise, registrants may request that all fees be applied to another training later in the same calendar year provided that IPAS is notified of the trainee's need to reschedule by 3:30 PM a full seven calender days prior to the start of the class. A request for rescheduling received after this, deadline, for any reason, will only allow the trainee to apply $135.00 of the registration fee to any class held during the proceeding 12 months after which none of the registration fee may be applied. My signature indicates that I have read this warning and understand the restrictions concerning no refunds and cancellation penalties. Failure to sign will result in the return of your check and not being registered for a class.
Signature for Notice and Warning

Do you wish to have your Registration Fee Returned should this Class be Filled ?
Signature for YES

YES, Please Return my Registration Fees. NO, Please Sign me up for the next class.
Signature for NO

Do Not Write Below, For office use only:
Check no. Date Check Returned and by whom:

Receipt no. and entered by whom:

Date confirmation sent and by whom: