Workshop Registration Form

First Name

Last Name

Work Info

Position

Program / Company

Address

City

State

Zip

Phone

FAX

E-mail

Home Info (optional)

Address

City

State

Zip

Phone

  Send correspondence to: Work Home

Workshop registration (enrollment is limited)

*Early Bird
(30 days prior)

Regular Tuition

Challeng Course Facilitator Training

$425

$495

Critical Skills for Safety ©

$425

$495

Elements Of Choice ©

$255

$325

The Innovative Team ©

$365

$425

How did you hear about this workshop?

Who referred you?

PAYMENT METHOD

U.S. FUNDS ONLY

We accept the following forms of payment:

Checks, Mastercard and Visa

Please make CHECKS payable to:

Leahy & Associates, Inc.

If paying by CREDIT CARD -- please CALL US @

303.673-9832 with your payment information.

Full payment must accompany registration form

to be registered.

Early Bird Rates apply only when accompanied with payment.

• Please enclose tuition and separate enrollment form for each participant.

• Meals and lodging are not included.

• Refund policy: Written request must be sent for any refund. (Call first.) Tuition minus a $50.00 process fee is refundable up to 30 days before the start of the workshop. Refunds after that date are issued less a $100.00 process fee. NO SHOW POLICY: NO REFUND. If Leahy & Associates, Inc. cancels or post-pones any workshop, 100% of the tuition is refundable