Boston Institute for Psychotherapy - Film Series Registration

PLEASE READ
Full payment must accompany mailed registration. Only one form per registrant, please.
Names of registrants will be held at the door
(no confirmation will be sent).

Refund Policy: Refunds (less a handling fee of $5) will be made for cancellation requests received by 5:00 pm, seven days before the film.

No refunds will be given for full series registration cancellations after March 7, 2009. All refunds will be made post-series.

2009 Film Series Registration Form

Film Selections:

March 13 - The Woodsman, 2004; director: Nicole Kassell
Discussant: Donna LoBiondo, M.Div., Ph.D.

March 20 - A Rape in a Small Town: The Florence Holway Story,
2004; director: Jeffery Chapman
Discussant: Nancy Connolly, Psy.D.

March 27 - Capturing the Friedmans, 2003; director: Andrew Jacerki
Discussant: Nikos Tomich, Psy.D.

April 3 - Crash, 1996; director: David Cronenberg
Discussant: Gregg Belle, Ph.D.

Name:
Phone: ( ) -
Street:
City:
State:
Zip:
Email:

Please Check One of the Following:
$34 Film & Continuing Education Registrants
$14 Regular Admission
$7 Student

Series Discounts:
$50 All Four Films
$130 All Four Films (Continuing Education)

For Continuing Education Credit Only. Please check one
Licensure:
Pysch
LICSW
LCSW
LMHC
Other(specify)
License #: State:

Payment Type:
Check
Charge

Membership Code (if applicable )