Registration Form - Wednesday, December 11, 2024 ARTFUL CONNECTIONS: EXPLORING ART THERAPY THROUGH THE LENS OF POLYVAGAL THEORY

Wednesday, December 11, 2024
ARTFUL CONNECTIONS: EXPLORING ART THERAPY

THROUGH THE LENS OF POLYVAGAL THEORY

Presenter: Lorie White, LCAT
9:00am - 12:00pm EST

FSS Training Room, 280 Princeton Ave. Ext., Corning, NY

or live-streamed online via Zoom
3.0 Contact Hours - $49/person

THIS IS AN IN-PERSON AND/OR ONLINE TRAINING EVENT.

SEATING AT THE FSS TRAINING ROOM IS EXTREMELY LIMITED FOR THIS EVENT

CONTACT INFORMATION

First Name *

Last Name *

Organization

Mailing Address *

City *

State *

Postal Code *

Contact Phone: *

Email Address *

Will you be attending in-person at our FSS Training Room in Corning, NY, or online via Zoom? *

In-Person (Corning, NY)

Online via Zoom

New York Social Workers, Creative Art Therapists, Mental Health Counselors, and Marriage & Family Therapists

New York requires a license number on the continuing education certificate for the following disciplines. Please indicate if you hold any of the following NEW YORK state licenses/certifications:

If applicable, lease provide your NY state license number (for CE certificate purposes; if you have a PA-issued license, you do not need to submit your license number)

For Pennsylvania State Board of Social Workers, Marriage and Family Therapists and Professional Counselors

Pennsylvania State Board of Social Workers, Marriage and Family Therapists and Professional Counselors
The State Board of Social Workers, Marriage and Family Therapists and Professional Counselors recognizes Family Service Society (as a sponsor approved by the National Board of Certified Counselors NBCC - #5930), to be a pre-approved provider of continuing education programs for Social Workers (Sec. 47.36), Marriage and Family Therapist (Sec. 48.36), and Professional Counselors (Section 49.36).

NBCC

Do you need NBCC CE credit? Family Service Society, Inc. has been approved by NBCC as an Approved Continuing Education Provider, ACEP #5930. Programs that do not qualify for NBCC credit are clearly identified. Family Service Society, Inc. is solely responsible for all aspects of the programs. *

Yes, I need NBCC CE credit

No, I do NOT need NBCC credit

PAYMENT

Please select the training you are registering for: *

Wednesday, December 11, 2024 - $49 (Lorie White)

Payment Method - Please indicate your payment method below. FULL PAYMENT MUST BE RECEIVED PRIOR TO THE TRAINING ON December 11th or WE MUST RECEIVE A FULLY COMPLETED PURCHASE ORDER. Thank you!! Questions? Please call Janalee Orfanides at 607-542-5330 (Cell Phone). *

Credit Card

Check (made payable to Family Service Society) **When you submit this form you will be directed to PayPal - just exit out of it**

Purchase Order (fax a copy to 607-962-8422 or email it to orfanidesj@familyservicesociety.org) **When you submit this form you will be directed to PayPal - just exit out of it**

Other (e.g. agency partnerships) **When you submit this form you will be directed to PayPal - just exit out of it** Other (e.g. agency partnerships) **When you submit this form you will be directed to PayPal - just exit out of it**

You will be directed to Paypal where you may enter your credit card information. Please Note: You DO NOT need a Paypal account in order to pay by credit card.

If you are paying by check, purchase order, or via an agency partnership, please follow your registration through to the Paypal page and then EXIT OUT OF IT.

Cancellation Policy: Refunds will be given up until December 4, 2024, at midnight (EST). You must make your refund request via email ONLY to Janalee Orfanides at orfanidesj@familyservicesociety.org.

No refund requests will be accepted after December 4th at midnight. However, you will be allowed to substitute another person. PLEASE NOTE THAT ALL REFUNDS - made at any time - WILL INCUR A $5 CANCELLATION FEE.

I have read and understand the cancellation policy. *

Yes

Additional Information

If you are paying by check, please make the check payable to Family Service Society, Inc. and send it to the following address:

Family Service Society PTI

280 Princeton Ave. Ext.

Corning, NY 14830

WE ACCEPT PURCHASE ORDERS. They can be sent to the above address or via fax at 607-962-8422. Or they can be scanned and emailed to orfanidesj@familyservicesociety.org.

Questions?

Please contact Janalee Orfanides, Director of Communications & the Professional Training Institute, at orfanidesj@familyservicesociety.org. You may also reach out to her at 607-542-5330 (Cell Phone).

Comments/Questions/Additional Information