Please print this form, fill it out, and fax or mail to us at:
Mental Research Institute
555 Middlefield Road
Palo Alto, CA 94301 USA
Tel: (650) 321-3055   Fax: (650) 321-3785   Email: mri@mri.org

Name: ___________________________________________________
Address: ___________________________________________________
___________________________________________________
___________________________________________________
Telephone: ___________________________________________________
Fax: _____________________________________
Email: _____________________________________

Check one or two of the following:

$250.00 USD  Strategic Therapy Intensive - July 20-21, 2007
 $125.00 USD  Therapy with Oppositional Youth - July 28, 2007
 $250.00 USD  Strategic Therapy Intensive - October 19-20, 2007
 $125.00 USD  Therapy with Oppositional Youth - October 27, 2007
 
Payment Method:

Check (payable to "MRI")   Visa     Mastercard

Name as it appears on credit card:  ____________________________________

Card #  __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __        Exp Date: __/__

Signature:  X_____________________________________________


Refund and Cancellation Policy: Please read and sign below
  • 100% refund of fees for cancellations received at least two weeks prior to the start of the course, training, or residency.
     
  • 80% refund of fees for cancellations received less than two weeks prior to the start of the course, training, or residency.
     
  • MRI reserves the right to cancel any course or training program if there is insufficient enrollment. In the event that we cancel a course or training program, we will refund to you 100% of your fees.

I have read and understand the refund and cancellation policy outlined above:

Signature of registrant:  X______________________________________