DIRFloortime® 101 Registration
Congratulations in your pursuit of learning more in the service of children!

MedMom Child Development Clinic is looking forward to having you for the workshop. Please provide your information below to continue with your registration. One form per applicant.

Workshop Details
Date: April 7-8, 2016

Venue: Dolcelatte Cafe, 1616 Quezon Ave., South Triangle, Quezon City

Local participant
Regular rates = Php 10,000
International participant
Regular rates = Php $250


General Information
Name (Last name, First name, M.I.) *
Your answer
Date of birth *
Country *
Your answer
City *
Your answer
Profession *
Name of Institution *
Your answer
Contact Information
Your answer
Mobile *
Your answer
E-mail address *
Your answer
Mode of payment *
Questions or Comments
Your answer
Thank you for registering!
Please expect a confirmation e-mail from us within 24-48 hours once you've submitted this form. We accept direct payment in the clinic or via BPI bank deposit in order to reserve your slot for the workshop. Instructions will be included in the e-mail.

Should you have any questions, please get in touch with us at (632) 234-2554 or administrator@med-mom.com (subject title: DIR 101 inquiry).

Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms