Registration Form

To register please print out this page and mail with your check made payable to:

Baltimore Washington Institute for Psychoanalysis
14900 Sweitzer Lane, Suite 102
Laurel, Maryland, 20707

Name of Program:

Applicant's Name:

Mailing Address:

 City State Zip:

Home Phone:

Office Phone:

Email Address:

Place of Employment:

Address:

City State Zip

How did you learn about this program? _____________________________________

Are you interested in receiving notices of future programs? ___ Yes ___ No

Some of our programs may be of particular interest to professionals with specific backgrounds. Are you a:

(Please check all that apply)

___Clinical Social Worker

___Psychologist

___Psychiatrist

___Counselor

___Psychoanalyst

___Family Therapist

Seminar/Workshop Fee:

Refunds will be given for cancellations not later than one week prior to the program.

Pre-registration by Feb. 20, 2009 $90____

On-Site Registration $110___

Residents and Students* $45___

*Indicates student enrolled in a degree-granting program.

Name of school*_____________________________

Lunch included. Choice of lunch entrée (check one)

___Poultry___Vegetarian