Domestic Mediation Training
Date: October 29-31, 2018
Location: Kaufman House Training Facility, Bethel College
2515 College Avenue
North Newton, KS 67117
Name
Name as you wish it to appear on course certificate and name-tag. One registration form per person required.
First Name *
Your answer
MI
Your answer
Last Name *
Your answer
Organizational Affiliation/Title
Your answer
Prior Core Mediation Training
Core mediation training is a pre-requisite for this course.
Where did you take your Core Mediation Course? *
Your answer
Date course completed? *
Your answer
Mailing Address
Street Address/PO Box *
Your answer
State/Province *
Your answer
City *
Your answer
ZIP (Postal Code) *
Your answer
Work Phone *
Your answer
Home Phone
Your answer
Cell Phone *
Your answer
Email Address *
Your answer
Registration Fee
$400 if the $75 non-refundable deposit is received by October 5, 2018; $450 thereafter.
Refund Policy
If you must cancel your registration, do so as soon as possible. A refund, minus a $50 processing fee, will be made if cancellation is received no later than seven days prior to the training.
Cancellation Policy
KIPCOR may cancel or postpone any training course because of insufficient enrollment or other unforeseen circumstances. If there is a cancellation or postponement, liability is limited to the registration fee.
Additional Registration Information
I request information regarding college credit.
I wish to receive Continuing Education Units for Social Workers
Special dietary requirements? If none, leave blank.
Your answer
Special assistance required? If none, leave blank.
Your answer
Form of Payment *
Checks made payable to KIPCOR can be mailed to KIPCOR, P.O. Box 276, North Newton, KS 67117. Please call our office at (316) 284-5217 to make a credit card payment. Forms of credit accepted are Discover, MasterCard, and Visa.
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