Course Registration Form

 MPC  Course Registration Form 

 

Name: ____________________________________________

Address:__________________________________________

  _________________________________________________

Occupation:_______________________________________

Phone:____________________________________________

E-mail:____________________________________________

 

MPC Member Status:  

Member _____      Non-member  _____     Candidate  _____

 

List courses by name and term:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

 

Send form with a check payable to 'Michigan Psychoanalytic Council' to:  

Rebecca Hatton, Psy.D., Registrar
2035 Suffolk
Ann Arbor, Michigan 48103
 
734.709.2183
rebecca.hatton1@gmail.com

 

Full payment is due by the second class meeting unless prior arrangements have been made with the Registrar. 

Acceptance of students for specific courses will be based on previous education and the decision of the course instructor and the Training and Certification Committee.