Full Name:
Select One: Self-employed    Full-time    Part-time    Student
Are you a social worker or a counselor? Yes No    License #    State
 Will we be issuing you a CEU certificate for social work or counseling hours? (11 core)   Yes No
if so, how would you like your name to appear on your CEU certificate?
 Name of your company:

Home or office mailing address:

    State:     ZIP:
Cell phone:  -   -    
Work phone:  -   -    
  Fax:   -   -    
E-mail address:
Confirm E-mail address:
Website (if applicable):
How did you hear about this training? Internet    E-mail     other

if other, please explain below:

Workshop you are registering for: August 23rd - 24th, 2014: Woodstock, GA
Method of payment: Cash   Check    Purchase order   Paypal*
Exp date:   
  Please call or e-mail us to register for 2 people at once.

Please call Craig at (770) 517-3363 ext 3, or on his cell at: (404) 520-0221.

Please make checks payable to: Blue Skies CCH, INC.

*Please return to trainings page (click the back button once) to pay using Paypal