Registration Form

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:____________.

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:

the Book, $54.95 PLUS
___the Video ($89) OR ___the CD ($97)
(check only one)
PLUS
the Registration Fee, $338*

For a TOTAL of: $481.95 (with the Video) or $489.95 (with the CD).
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/cd, be sure to subtract the correct amount (see prices above) from your total:

After you pay, remember to come back to THIS page to print it out and mail it. 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

This registration form and your check (made out to "Pro-Education Media") should be sent to:
          Pro-Education Media
          c/o Prof. Howard Seeman
          20 River Court - Suite 1404
          Jersey City, NJ    07310
or you may fax it to 201-420-6555 (Faxing? Send alert to: Hokaja@aol.com )
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 Hokaja@aol.com.

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If you aren't, at this time, interested in the course, but wish to purchase all or some of the materials above. Go to: http://www.panix.com/~pro-ed
If you aren't, at this time, interested in the course, but just wish to consult with the instructor, confidentially, on a "per question fee basis". Go to: http://hometown.aol.com/hokaja/
If you are interested in becoming a paid Instructor of this online course and/or a paid Workshop Leader of these skills. Click here
I am not interested in the course now, but want information about having an online classroom management consultant for my school. Click here

*************************************************** 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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