Registration Form
Below is a sample registration form that needs to be completed to reserve a spot in one of the training sites. To download the form click here (saved as a .pdf file).
Yes, sign me up for the School-Neuropsychology Post-Graduate Certification Program.
I am enclosing a deposit check for $500.00 payable to KIDS, Inc. to secure a position in the class. I understand that enrollment is limited to ensure adequate supervision. Classes will be filled up based on those who send in their registration forms first.
The balance of the tuition will be payable no later than
six weeks prior to the start of the course. School purchase orders will
be accepted.
Name of the Site You are Registering For (e.g., Irvine, CA): _________________________
Name: _____________________________________
Address: ___________________________________
City, State Zip: ______________________________
Home Phone #: ______________________________
Work Phone #: ______________________________
Cell Phone #: ________________________________
Email Address: ______________________________
Work Position (e.g., Certified/licensed school psychologist, clinical psychologist, etc.): ___________________________________________
We accept Purchase Orders, Check, Mastercard, VISA, or
Discover:
Card #:____________________________________ Exp. Date (mm/yy):____________
3 digit security code on back of card: ________
Name on Card: _____________________________
Questions: Call Dr. Miller at:
940-497-KIDS (5437) Work
940-206-0504 cellor email to danielcmiller@earthlink.net
Send tuition deposit ($500) and completed registration form to:
KIDS, Inc.
1156 Point Vista Road
Hickory Creek, Texas 75065or fax to (940) 497-2127