Divorce Education Program Registration Form
(MAIL or FAX)

Space is limited, pre-registration is required. The cost is $80.00 per person.

To register by phone using a VISA/MasterCard, Call (781) 551-0999 or fax this form
to (781) 551-3396. You can also mail it to us (see address below).

Name on Card: _____________________________________________

Visa / MasterCard No. _____________________________________

Expiration Date: ____ / ____

___________________________________________________________
Your Signature

To register by mail:
Fax this form with credit card payment information to (781-551-3396) or mail it
with a check for $80.00 made payable to CFPS, Inc. to:

Child & Family Psychological Services
89 Access Road, Unit 24
Norwood, MA 02062

To register by email:
Complete this form and send by email to: cmaniscalco@cfpsych.org

Name: ____________________________________________________

Address: _________________________________________________

__________________________________________________________

Home Phone: (_____) __________________

Work Phone: (_____) __________________

E-mail Address: ___________________________________________

Fax No.(_____) __________________

Name of other parent: ____________________________________

Dates of Seminar: ________________________________________

REGISTRATION WILL BE CONFIRMED BY MAIL IF TIME PERMITS. OTHERWISE YOU WILL BE CONTACTED BY PHONE OR EMAIL.