Domestic Mediation Training

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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 *

Last Name *

Organizational Affiliation/Title

Prior Core Mediation Training

Core mediation training is a pre-requisite for this course.

Where did you take your Core Mediation Course? *

Date course completed? *

Mailing Address

Street Address/PO Box *

State/Province *

City *

ZIP (Postal Code) *

Work Phone *

Home Phone

Cell Phone *

Email Address *

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.

Yes

Clear selection

I wish to receive Continuing Education Units for Social Workers

Yes

Clear selection

Special dietary requirements? If none, leave blank.

Special assistance required? If none, leave blank.

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.

Check to be mailed

Credit card charge

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Forms

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