Basic Training Application Form
EMDRResourceCenter of Michigan
Basic EMDR Training: EMDRResourceCenter of Michigan
Trainers: Zona Scheiner, Ph.D. and Bennet Wolper, LMSW
Name (as you want it on your certificate):______
Street Address: ______
City ______State ______Zip Code:______
Email: ______
Phone (work): ______
Phone (Home): ______Phone (cell) ______FAX______
Highest Degree:______Field of Study______
EMDR training is available to licensed mental health professionals or people working toward
Licensure, under the supervision of a licensed professional. Please provide the following
information regarding your licensure situation.
□Licensed Professional Type of License: ______License No.:______
Supervised by: ______
□Student in Internship Supervised by: ______
Type of License: License No.:______
How did you learn about our training?
_____ EMDR-trained colleague: ______
_____ Web search (which engine, eg. Google, Yahoo….) ______
_____ Advertisement (please indicate where)______
_____ Email notice
_____ Attending one of our presentations: ______
Training Schedule and location:
Location: Zal Gaz Grotto Club
2070 W. Stadium Blvd
Ann Arbor, MI 48103
Dates: Wednesday - Friday, April 25 – 27, 2018
Thursday - Friday May 31-June 01, 2018
Thursday - Friday, September 06 – 07, 2018
Schedule: Registration and continental breakfast: 8:30 a.m.
Workshop: 9 a.m.-5:30 p.m.
*Consultation Dates:
To be determined
Fees
□$1725(Before February 1, 2018)□$1775((Before March 15, 2018) □$1825(After March 15, 2018),($50 discount for check/cash payments)
Groups of 5+, Full-time Grad Student/Intern, or full-time non-profit employee:
Only one discount per registration as group, student or Nonprofit*
□$1575(Before February 1, 2018)□$1625(Before March 15, 2018)□$1675(After March 15, 2018),($40 discount for check/cash payments)
Payment:** If application submitted prior to December 15, 2017, please include a $100 deposit (refundable if program cancelled). By January 1, 2018, please submit 50% of the cost of the training.
If application December 15, 2017 or later, please include fifty (50)% of the cost of the training with the application. The balance is dueno later than 30 days prior to the first day of training. Applications submitted within 30 days of the beginning of training should be paid in full at the time of registration.
Cancellation policy: Full refund minus $100 up to 30 days before training.), Full refund minus $150 up to 14 days before training. No refund later than 14 days before training (unless another participant signs up for the program). In the case of an emergency, the Trainers may transfer the payment to the following year’s program.
Payment: You may pay tuition by check or credit card (VISA, MC,). If you are paying by check, pleasemail thisalong with your registration package and make check payable to EMDR Resource Center of Michigan. If you are not accepted into the program the voided check will be returned to you. If you are paying by credit card, you may provide credit card information on the registration formor you may phone the office with that information. A charge will made to your accountonly after you have been accepted into the training.
Participant Signature:______Date:______
Send this form with deposit to:
EMDRResourceCenter of Michigan
c/o Sandra Helm
3350 Beaumont Rd
Ann Arbor, MI 48105
Phone: Zona: 734 707-1322 or Bennet 734 646-9359 Sandra Helm (our assistant) 734 996 8231
Fax: To be arranged if needed
Please do not require a signature on delivery or mail might be returned to you undelivered.
Credit Card Number: □Visa □ MC
______
Card Number Amount charged
______
Security Number (the last 3 digits on the back of your card): ______
Name of Card Holder: Signature of Card Holder ______
Expiration (MM/YY):
IMPORTANT; Address, City, State and Zip if different from applicant address
*If you are applying either as a full-time employee of a Non-Profit or a Grad. Student/Intern you will need a letter from your agency indicating that you will be allowed to practice EMDR Therapy.
**Any change in payment plan will need to be discussed with trainers
PLEASE PRINT OUT THIS FORM, COMPLETE IT AND MAIL (do not require a delivery signature!) as part of a COMPLETE APPLICATION PACKAGE.. PLEASE INCLUDE A COPY OF YOUR CV OR RESUME AND A COPY OF YOUR PROFESSIONAL LICENSE.ALSO, PLEASE PRINT OUT A COPY OF THE PARTICIPANT'S AGREEMENT FORM, REVIEW AND SIGN THE FORM AND INCLUDE THIS WITH THE APPLICATION PACKAGE. IF APPLYING FOR AGENCY DISCOUNT, PLEASE SUBMIT the AGENCY DISCOUNT FORM FROM REGISTRATION SECTION OF WEBSITE.
INSTRUCTIONS TO APPLY FOR EMDR BASIC TRAINING PROGRAM
Please Mail* ALL OF THE FOLLOWING EMDR Resource Center c/o Sandra Helm 3350 Beaumont Rd, Ann Arbor, MI 48105 or attach to email to
Faxing available if needed
1) All pages of theRegistration Form. Thismust reflect your payment selection (see below for payment terms);
2) A signed and dated copy of the Participant's Agreement Form;
3)A current copy of your CV or resume;
4) A copy of your current professional licenseOR if you are not licensed for independent practice, please send a letter indicating when you will be licensed. If you are being supervised by a fully licensed practitioner, please include a statement by your supervisor that they are in support of your training in EMDR.
5) if applying for a mental health agency discount, include the Agency Discount Form
6. A brief cover letter indicating why you have chosen to apply for this program at this time.
Note: Incomplete registrations will not be processed and may face significant delays; we MUST receive ALL of these forms to process your registration.
**You maymail the entire package to EMDR Resource Center of Michigan c/o Sandra Helm 3350 Beaumont Rd., Ann Arbor, MI 48105. If you are not accepted for the training, your check will be returned to you.
*Consultation locations to be arranged. It is possible that one of the sessions will be on the telephone or online.
EMDR Resource Center of Michigan
Basic Training Registration Form