8340 Meadow Road

Suite 136

Dallas, TX 75231-4278

Phone: 214-696-4278

ATI Course Registration Form

For students paying by check, please complete the form below and mail it to the Art Therapy Institute at the

address above. Registration by check must be received ten days prior to the beginning of class. For students

paying by credit card, please select the credit card payment option online.

NAME_______________________________________________ EMAIL______________________________

ADDRESS______________________________________CITY__________________STATE____ZIP_______

PHONE: AM_________________PM________________CELL________________FAX_________________

CHECK ALL THAT APPLY
SUMMER 2007
	6008-010 – Group Supervision - Friday, October 12, 2007	$150.00
	6008-011 – Group Supervision – Saturday, October 13, 2007	$150.00
	6008-012 – Group Supervision – Friday, March 14, 2008	$150.00
	6008-013 – Group Supervision – Saturday, March 15, 2008	$150.00
	6007 – Final Project – Continuation Option	$900.00
ADDITIONAL FEES
	Check here if you are paying for a course continuation – additional term	$900.00
	Check here if you need to pay for a Late Course Completion.	$20.00
	Check here for if Same Day or Late Course Registration.	$20.00
	Drop Fee	$30.00
	Transfer of Credit Fee ($20 per Credit Hour)	$20.00
	Official Transcript Fee (1^st request is free)	$15
TOTAL ENCLOSED

Refund Policies: Refund for cancellations before the first day of class is 100%.

Acknowledgement: Certificate Students should enroll in Online Courses, Seminars and

Group Supervision Workshops following advisement. Licensed mental health professionals,

graduate students of Mental health programs, and graduates of the ATI are also eligible to

enroll in Seminars and Online Courses. Group Supervision is restricted to eight (8)

participants and is open to Certificate Students and art therapy interns only.

_________________________________________________ ______________________

Signature Date