Registration Form
Workshop: Involving Parents & Caregivers in Play Therapy
Presenter: Dr. Rachel Copeland, PhD, LCSW, PIP, RPT-S
Date: November 9, 2015
Time: 9:30am-4:30pm
Registrants Information
Name:__________________________________________________________________
Agency/Graduate Program: _________________________________________________
Job Title: _______________________________________ Degree: __________________
Mailing Address: __________________________________________________________
City: _______________________________State: ______________ Zip: _____________
Phone: ____________________________ Email: _______________________________
Payment Information
Credit Card ____ Check ____
Name on card:
Credit card # __________________________Exp. Date _________Security Code: ______
Please provide credit card information above or make checks payable to The Safe Center LI and mail to:
The Safe Center LI
Attention: Katie Shaw
15 Grumman Road West, Suite 1000
Bethpage, NY 11714
***Early Registration Deadline: Friday, October 16th
Professionals (early registration) _________$95
Professionals (after 10/16) _________$110
Graduate Students (early registration) _________$80
Graduate Students (after 10/16) _________$95
If you are interested in obtaining APT continuing education credits, please contact Katie Shaw at kshaw@tscli.org . We may offer ceus if enough people are interested.