Course Application

Step 1: Course Signup

Please fill out the form below to register for the course titled
"Building Better Angels - With Evidence Based Child & Family Therapy"
Seating is limited for this course.

*Course Date:	If you are unable to attend any of the listed dates for this course, please email Dr. Doug Larson to arrange for special accommodations.
*Salutation:
*First Name:
*Last Name:
*Professional Affiliation:
License Number:
CPA or IPA number:

*Email Address
*Phone Number
*Will you be taking this course for CEU credits?:

	*Optional Information*: We'd like to know where and when future courses would be convenient for you, based on your location and schedule throughout the year. Please take the time to answer these three questions so we can better accommodate our course registrants:

Preferred Location: (check all that apply)	Los Angeles Santa Barbara San Diego San Francisco Sacramento

Preferred Days: (check all that apply)	Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Preferred Months: (check all that apply)	January February March April May June July August September October November December

*Payment Method:
	If you are going to be using PayPal to register you must provide the information below. If you need to cancel your registration and you have paid by PayPal, you will receive your payment less $20.00 for processing fees. Cancelled registrations will be refunded within 30 calendar days. Cancellation requests can be sent to cancelregistration@drdouglarson.com Additionally, if you are an IPA Member, you can email Dr. Doug Larson for special rates and accommodations.

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	From time to time, DrDougLarson.com sends special offers and news about new courses to its registered applicants. If you would not like to receive any emails about these special offers, please specify below. DrDougLarson will never sell your email address to any third parties and maintains the highest level of professional courtesy to all registered applicants.
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