Registration Form

To register, please complete the form below then select 'Submit' to email it directly to our office,
or select 'Print This Form' from the top of this window to mail or fax the form to our office.

Please call our office at 416.391.3110 if you do not receive an email confirmation
of your registration within 2 business days, or we cannot guarantee receipt of your registration.

If preferred payment is by credit card, please complete the additional information on the form before submitting.

If printing, please include your signature before faxing or mailing the form.
Please print clearly and keep a copy for your records.

Receipts for Course Registration Fees provided on the first day of course

PLEASE ENTER YOUR NAME EXACTLY AS YOU WOULD LIKE IT TO APPEAR ON YOUR CERTIFICATE, INCLUDING FORMAL DEGREES AND DESIGNATIONS.

Name:

Degree:

Employer:

Profession:

Address:

City:

Province:

Postal Code:

Home Phone:	*	Business Phone:
Fax:		Additional Phone:
Email Address:

Please enroll me in the following program:
*

Payment method:	Cheque	Visa	Mastercard *

If payment by credit card, please fill in the following:

Account Number:

Expiry Date (mm/yy):	/

Signature:	______________________________________

Today's Date (mm/dd/yyyy):	/ /

Please make cheques payable to "Dr. Barbara Landau"

I found out about this course through:
	ADR Institute

	Conrad Grebel School
	Other University
	Through Work
	A Friend or Colleague
	A Publication Please Specify:

**NOTE: Registration cut off is 14 business days prior to course start date.
Any registrations received after that time will be subject to an additional $75 administration fee. We cannot guarantee a seat in our classes unless we receive registration fees in advance of the course

* Cancellations: Written notice required. Prior to 8 days before course starts: Refund less $160.00 Administrative Fee. Within 7 days before course starts: No refund.

* As required by the Mediation Associations, the full course must be completed within one year.

Deferral to a later course: Written notice required. Prior to 14 days before course starts: No Administrative Fee. 8 to 14 days before course starts: $80.00 Administrative Fee. Within 7 days before course starts: $160.00 Administrative Fee. Substitution of registrant is permitted.

Mail completed Registration form &
cheque payable to "Dr. Barbara Landau" to:

Cooperative Solutions
76 Truman Road
Toronto, Ontario M2L 2L6
Canada

For more information:

Mary-Anne Popescu at Cooperative Solutions
Phone: (416) 481-3651
Phone toll-free 1 (888) 595-5534
Fax: 416-391-2347
mpopescu@coop-solutions.ca

Print This Form