PRIVATE APPOINTMENT WITH GEORGE ANDERSON--PRINTABLE REGISTRATION FORM

Please fill out this form and mail it to us with your payment/deposit to the address below.  Processing usually takes 3 weeks.  A confirmation letter will be sent via return mail indicating the date, time and location of your session.  Payment may be made by check or money order. (U.S. funds only.)    For international registrants, we can only accept International Postal money orders or checks made in U.S. funds from a U.S. Bank

Cost per session:     (children under the age of 16 may attend with a parent/guardian at no charge)
1-2 persons   1200.00                  
   3 persons   1700.00 
   4 persons   2200.00 
       Family    2000.00    (Up to 6 immediate family members, making contact with the SAME family member )

Deposits     For those who wish to hold an appointment and send the balance of funds over time, we will gladly accept a deposit for  50% of the session fee, provided the balance is paid in full by no later than 30 days before the scheduled program date. Upon your initial deposit we will reserve a spot for you in your program of choice, and send you an acknowledgement of your deposit, the date, the time and the location of your appointment. When the balance of funds is paid in full we will issue your confirmation letter which you will need to bring with you to the session.

Refunds     You have until 24 hours before your appointment to receive a full refund of your session fee or deposit. We regret that after the date of your scheduled session, the registration fee/deposit is non-refundable. As long as we are notified by the day before your scheduled appointment, we will be happy to refund your full session fee.  By filling out the form below, you acknowledge that you understand and accept the terms herein.

PLEASE ALLOW 3 WEEKS FOR YOUR REGISTRATION TO PROCESS AND RECEIVE YOUR CONFIRMATION
---------------------------------------------------please detach and send with your payment-------------------------------------------------

George Anderson Grief Support Programs --PRIVATE SESSION Registration Form

Enclosed, please find my      _______ deposit       ______payment in full for ___ persons for a  private  session on:

 ____TUESDAY,  MARCH 3  ____WEDNESDAY,  MARCH 4   ____THURSDAY, MARCH 5, 2009
 all appointments are scheduled between 3PM and 7PM  

If the date I requested is full at the time you receive my request, please: (check one)
_______PLACE ME IN THE SOONEST AVAILABLE DATE     _______CANCEL MY REGISTRATION AND RETURN MY FUNDS

 I have made my check/money order in US FUNDS payable to:
George Anderson Grief Support Programs   Post Office Box 733   Deer Park, New York 11729 

Please send my confirmation letter to: (please PRINT--we must return any form which is illegible)

Name: _____________________________________________________________________________________
Address:___________________________________________________________________________________
City:______________________________________State_________Zip Code____________________________

Contact number: (required--we will not process your registration without one)_________________________