REGISTRATION FORM
Addiction Professional Training Program Registration Form    

Name: __________________________________ Home Phone:____________Work Phone:____________

Address:_______________________City____________State/Zip___________  email:_________________

CERTIFIED ALCOHOL & DRUG COUNSELOR CLASSES (270 Hours) :   

  Beginning Date: _____________

Select Location:
____ 1. Cherry Hill: Hosted by Kennedy Health Systems, Stratford Campus. Stratford, NJ
____ 2. Elizabeth: Hosted by Trinitas Hospital. Elizabeth, NJ
____ 3. Plainfield: Hosted by Organization for Recovery, Inc. Plainfield, NJ
                  
_____ Selected Courses   (use grid below to indicate selected courses) ) use additional sheet if necessary
_____ $50 each 6-hour class
_____ $360 Payment by Domain, (must be paid in advance - includes 10% discount)
_____ $1350 Full Payment, (must be paid in advance-includes 10% discount)
_____ Outside Funding Source by Payment Voucher:
$2250 in full or 4 equal installments of $562.50 each (must be received in advance of class attendance)

Course
No

Course Title

Date(s)

Location*1

Fee

         
         
         
         
         
         
         
         
         
Total Registration Fees Due


 

Payment Method:   
 ____ Payment Enclosed $________                                                                                      
 ____ Outside Funding Source:     Contact Name :____________________________Telephone: __________________
            Agency Name/Address:__________________________________________________________      
____ Credit Card Payment: (circle one) Master Card - VISA - Discover      Exp. Date:__________
           Credit Card #____________________________________ CVV2 Code:________
           Signature:_______________________________________


Mail registration & Payment to:  OFR CPDD, P.O. Box 827, Plainfield, NJ 07061

No Show Policy
If you register and prepay for classes and do not attend, you are liable for the full registration fee unless a written cancellation notice is received 7 working days prior to the date of the actual class. There will be no refunds issued for cancellations received in less than 7 days. Please contact the OFR CPDD at 908-769-4700 ext. 20 or via email at education@organizationforrecovery.org if you are unable to attend within the designated time allotted.

Cancellation Policy
Organization for Recovery reserves the right to cancel classes due to low attendance or for inclement weather. If Organization for Recovery cancels a class, registrants who have prepaid will be given full refunds, credit towards the rescheduled canceled class or a future class. However, Organization for Recovery is not responsible for any out of pocket expenses directly or indirectly sustained by the registrant.


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