This form needs to be received at least 2 days prior to the start of the class.
Please print this page to fill it out
I, (please print) ____________________________ wish to register for

Preventing Classroom Discipline Problems; The Online Course

for Session #____ , which begins on:__________________.

(If signing up for an Individual Tutorial, leave above line blank and choose a start date:__________________.)

How did you hear about this course?____________________________________.

Type here a confidential Course Nickname, one that no one would know is you:_______________________.

My email address is: (print carefully)____________________________________.

My phone no. is: (_____) ________________

Enclosed is my check (or you can use PayPal) for:

FOR K-12 TEACHERS the K-12 Book, $64.95 ___the Video on VHS (playable on a VCR): $69 OR ___ the Video on DVD: $97 (Both versions have the exact same content.) the Course Registration Fee or Individual Tutorial, $338* For a TOTAL of: $471.95 (VHS) or $499.95 (DVD).

FOR COLLEGE TEACHERS the K-12 Book, $64.95 the College Book, including shipping: $39.95 the Course Registration Fee or Individual Tutorial, $395.05* For a TOTAL of: $499.95

FOR 3-6 HOUR MODULE/SESSION the K-12 Book, $64.95 ___the Video on VHS (playable on a VCR): $69 OR ___ the Video on DVD: $97 (Both versions have the exact same content.) Feedback and Guided Reading of the Book from Prof. Seeman: $98 For a TOTAL of: $231.95 (VHS) or $259.95 (DVD).

This is usually a tax-deductible, job-related expense. Your school may pay this fee; See FAQs.

You may also pay with your credit card, securely, via PayPal:
If you already have the book or video, be sure to subtract the correct amount (see prices above) from your total:

After you pay, remember to come back to print and mail this page. OPTIONAL: I wish to apply to become a paid Instructor of this Online Course and/or paid Workshop Leader. Also enclosed is my separate check of $300 for this training.
Go to Application for Instructor/Leader

If you would like to pay by check, make it out to "Pro-Education Media" and send to:

       Pro-Education Media
       c/o Prof. Howard Seeman
       20 River Court - Suite 1404
       Jersey City, NJ    07310

If you need to pay using a Purchase Order you can:

     • Mail it to the above address,
     • Send it as an attached file to [email protected], or
     • Fax it to: (201) 420-6555.

(If you do any of the above, send an email alerting this, to [email protected])

Check-off payment method:
_____ check enclosed
_____ I used PayPal on: ___/___/___
_____ I have mailed/faxed a Purchase Order

*If you are not completely satisfied with the course, or find you cannot do the course satisfactorily at this time, the Registration Fee ($338) will be fully refunded, as long as your request for this refund is received via regular mail, signed by you, within 10 days after the start-date of the course.

Please send me confirmation of my registration via email, and the course materials to:

Name: (print clearly)___________________________________________

Address:_____________________________________________________

____________________________________________________________

City:______________________   State:____   Zip Code:_______________

To reserve a place in the session of your choice, or to request a revision in the course that may be better for you, email Prof. Seeman at [email protected].

*************************************************** *************************************************** Any distribution of course files to non-registrants, or use of this course, whole or in part, without the permission of Prof. Howard Seeman is a violation of federal copyright laws.

Please sign:___________________________________  Date:_________________

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