REGISTRATION FORM
Name
____________________________________________________________________________________

Address
__________________________________________________________________________________

City ________________________________________        State _____________________        Zip ________

Home Phone _________________       Cell Phone ___________________        Work Phone _______________

Email ____________________________________________________________________________________


   Program        Name                                                                                        Weekly Cost        Total        
  #700101       7-WEEK ONE ON ONE PROGRAM                                                         $30        $210        
  #700102       12-WEEK GROUP PROGRAM                                                                $20        $240        
  #700203       7-WEEK ONE ON ONE - HELPING CHILDREN DEAL WITH LOSS          $40        $280        
  #700204       7-WEEK GROUP – HELPING CHILDREN DEAL WITH LOSS                  $30        $210        
  #7009101                                                                                        Registration Fee                $ 25        
  #7009102                                                                                        Registration Fee                $ 25        
  #7009203                                                                                        Registration Fee                $ 25        
  #7009204                                                                                        Registration Fee                $ 25      

                                                                                                          Total Fees Payable        ________

                                      Credit Card Type                            Discount for Payment in Full        ________

           MC___  Visa ____ Amex___ Disc___                               Adjusted Fees Payable        ________
                                                                                               _____Check_____________        
          Credit Card #________________________                ____Charge_____________        
          Expiration Date______________________                ______Cash_____________        
                         Code_______________________

                                                                                                      Total Fees Paid Today        ________

                                                                                                                      Balance Due        ________


*Registration Fee covers cost of textbook and materials. Registration Fee is Non-refundable.  
Registration Fee is Transferable with original receipt.

By signing, I understand and accept the above listed terms of registration.

Signature___________________________________________________Date________________
8401 Shelbyville Road, Suite 203
Louisville, KY 40222
(502) 403-1086 - Phone
(502) 403-1074 - Fax
www.Jubalive.com

Grief Recovery® Outreach Program