REGISTRATION FORM

For Supervision Institute

Part I May 15-16 and Part II June 27-28, 2008

Please Print Legibly (or Type)

Date _________________________

NAME: _______________________________________________________________________

ADDRESS:  ____________________________________________________________________

CITY __________________________________________STATE _________ ZIP ____________

PHONE:         HOME (          ) ____________________________

                        WORK (          ) ____________________________

                        CELL   (          ) ____________________________

E-MAIL ADDRESS: ________________________________ FAX: (          ) ______________

NAME OF AGENCY/INSTITUTION:   __________________________________________

POSITION ___________________________________________

 I would like to register for the Supervisor’s Institute for:

   _____MFT (only)        _____ MFT and LPC (both designations)           _____LPC (only)         

REGISTRATION FEE: $50.00 due with registration .  Full fee may be paid at this time. If not, the remainder of the fee is payable on the first day of the Institute.

MAKE CHECK PAYABLE TO:  Our Lady of Holy Cross College (or “OLHCC”)

MAIL THIS REGISTRATION FORM AND PAYMENT TO:

 Our Lady of Holy Cross College

  Counseling and Training Center – LMFT/LPC Supervision Institute

Attn: Susan Wetwiski

4123 Woodland Drive

New Orleans, LA 70131-7399