Training Registration Form
Name (for certificate): _______________________________________________________
Name tag (First name or nickname):____________________________________________
Address (for Confirmation Letter):________________________________City/State/Zip:____________________
Home phone: _____________________Business phone:_____________________FAX:_____________________
Email Address:_____________________________________________________________
Place of employment: _______________________________________Position:___________________________
Describe any reasonable accommodations that we might need to make in order
for you to be able to participate in the training.
__________________________________________________________________________________________
How did you hear about The Justice Center of Atlanta?
Personal Referral _______ EMail Notice _______ JCA Web site _______ Other Web Site _______
Registration Information
Name of Training(s): ______________________________________________________________________
Date(s) of Training: _______________________________________________________________________
| Check Courses in which you are registering: | |||
| ___ | 3-day Advanced Mediation: Skills, Techniques, and Approaches, $695* | ___ | 3-day Mediation in Special Education, $695 |
| ___ | 5-day Basic Mediation Skills with Practicum, $1,390 | ||
*The cost for federal employees of Advanced Mediation: Skills, Techniques and Approaches is $693 per a GSA contract.
REGISTRATION & CANCELATION POLICY – Please read carefully:
To register for a class, JCA must receive the registration form with either full payment by check, a credit card number, or a completed 1556 form. Enrollees who cancel prior to the 1st day of class must, within 6 months, either register for and attend another class or request a refund in writing; otherwise all payments are forfeited to the Justice Center of Atlanta.
There is a $300.00 non-refundable no-show fee. In the case of a no-show, the $300 fee will either be charged to the credit card or a refund check will be issued minus the $300.00 fee. If a 1556 form was issued, we will invoice the government agency the $300.00 no-show fee. Refunds are issued to the payor of record.
I understand that my application for training at the Justice Center of Atlanta is not an application to become a mediator for the Justice Center of Atlanta. I also understand that completion of the training course conducted by the Justice Center of Atlanta does not necessarily qualify me to mediate for, or be accepted as, a mediator for the Justice Center of Atlanta.
Applicant Signature:_______________________________Date_____________________________________________
Payment Information - Please accept my deposit/payment
______ Cash/Check (Make checks payable to JCA)
______ Purchase order is attached. Send invoice to:
Contact Name:___________________________________________________________Charge to: _____VISA _____Mastercard _____American Express _____Discover _____Diners ClubAddress: __________________________________________________________
Phone: ___________________________ FAX:___________________________
Card #: _________________________________________Exp. Date:____________________________
Cardholder's Name:______________________________ Signature: _____________________________
Send completed application to: The Justice Center of Atlanta
Att: Training Services Department
976 Edgewood Avenue, N. E.
Atlanta, GA 30307-2580
Ph. 404.523.3613, ext. 236
FAX. 404.523.3936
E-Mail trish@justicecenter.org