Registration for NYMHCA Abuse Prevention Workshops
Date of Workshop Chosen:
Location:
Your Name:
Home Street Address:
Email Address:
Most Accessible Phone:
Are you a NYMHCA member?
Payment Options:
*1 Check. Print this form and make your check for$45 ($50 for non-members)
payable to: New York Mental Health Counselors Association
Mail to: NYMHCA
206 Greenbelt Parkway
Holbrook, NY 11741
*2 You Process Your Credit Card Payment
Credit Card Type:
Name on Card:
Credit Card Number:
*3 We Process Your Credit Card Payment
To process your credit card payment yourself please click on the
button above. You will be directed to ProfessionalCharges.com.
NYMHCA uses the secure payment processing services of
ProfessionalCharges.com to handle online credit and debit
transactions. You will need to type in the following ID# for
NYMHCA when processing your payment. That number is: 11-34578.
This charge will appear on your credit card statement as:"Professional Charges."
- If No, would you like membership material sent to you?
Profession:
*4 Print Off This Form and Fax It to Us With Your Credit Card Information. Fax Number: 631-472-3866
*5 Call us so we can process your payment for you! 1-800-4-NYMHCA
Refund and Cancellation Policy :
NYMHCA will refund 75% of the total registration fee only for cancellations received in writing 10 days prior to the workshop. Registration may not be transferred.
* Registered particpants who arrive more than 15 minutes late to a workshop cannot receive their certificate of completion. This is a mandate from the State Education Department. We suggest that you arrive 15-20 minutes early to ensure your admittance.
Employer:
Only click on this button if you have already paid by credit card.
If you do not receive an email confirmation of your registration, re-submit or contact our office.
City/Town:
State:
Zipcode:
Please remember to use your"back"button to return to this pageand click the "submit" button after paying! You will not be registered unless you do!
*NYMHCA has been authorized to provide 2 CEU's (continuing education units accepted by the National Board for Certified Counselors) for the 2-hour child abuse prevention workshop. Would you like to receive those CEU's after you complete the workshop?
Expiration Date:
Credit Card CVV#:
CVV is the 3-digit number printed on the signature panel on the back of your credit card. We cannot process your credit card payment without this number.
