Addressing Trauma in Pediatric Primary Care Registration

Addressing Trauma in Pediatric Primary Care
Registration Form

Please use the form below to register for an upcoming Addressing Trauma in Pediatric Primary Care course, where you will learn how to effectively detect and respond to trauma in the pediatric primary care setting.

Duration: One-day live course, followed by four (1-hour) group learning calls
Format: Virtual
Cost: $600

If the dates listed do not work for your schedule, please sign up to be notified of future training courses here.

This form is intended for registration of single participants. To register a group of participants, please email us at CATIE@thereachinstitute.org

Program Information

Program

Please select the start and end dates of your chosen program.

Start Date

End Date

Contact Information

Salutation

First Name

Last Name

Participant Email

The participant's email address must be entered for registration. All program communications prior to, during, and after the program require responses from the participant directly.

Phone

Please provide your mailing address below. Mailing address is required in order to receive program materials.

Mailing Country

Mailing Street Address

Mailing State/Province

Mailing City

Mailing Zip/Postal Code

Professional Information

With which license do you practice?

List other/additional licenses

What is your discipline?

List other/additional discipline

What is your occupation?

Organization/Practice Name

Organization/Practice Country

Organization/Practice Street Address

Organization/Practice City

Organization/Practice State/Province

Organization/Practice Zip/Postal Code

Referral Information

How did you hear about this training? (select all that apply)

A friend/colleague told me about this trainingI saw a social media postI found it on Google/search engineMy employer told me about this trainingI heard about it from REACH (newsletter, email, call group,, etc.)I found out about it from a professional association/publication/conferenceOther

Name of referral:

Select Platform:

Name of Employer

Name of association/publication/conference:

Referral Source:

Terms & Conditions

If you cancel your registration, the refund policy is as follows:

20 days or more prior to the course: 90% refund, minus credit card processing fees.
10 to 19 days: 70% refund, minus credit card processing fees.
3 to 9 days: 60% refund, minus credit card processing fees.
0 to 2 days: No refund.

Credit card processing fees: $77.00 for American Express or $48.70 for other credit cards.

I agree to Terms & Conditions

REACH does not sell or share any personal registration data.

Payment Information

Pre-Discount Total

Payment Amount

Promo code (if applicable)

Discount Amount

Name on Card

Card Number

Code

Billing Email

Billing Country

Billing Street Address

Billing State/Province

Billing City

Billing Zip/Postal Code

Contact Information

Addressing Trauma in Pediatric Primary Care Registration

Addressing Trauma in Pediatric Primary Care Registration