ICISF Group Crisis Certification Registration Form
ICISF Group Crisis Certification
(International Critical Incident Stress Foundation)
Registration Form
Space is limited. Register now!
October 4-5, 2019, 9:00 am - 5:00 pm daily
(must attend 9am-5pm both days to achieve certification)
ICISF Certified Instructor Dwight Bain
Training facility: Church on The Drive, 1914 Edgewater Drive, Orlando, FL 32804
PLEASE PRINT your name clearly as you would like it to appear on your National Certification
Name:__________________________________________________________
Address: _____________________________________________________________________
Telephone: _____________________________________________________
E-mail: ________________________________________________________
____ $199.00 - early bird registration (by September 6th)
____$219.00 - late registration (after September 6th if space is still available)
_____$5.00 (optional) if Continuing Education credits are required (13 contact hours provided)
Payment Options:
Please call to ensure that there is still space available before sending payment and registration
* Make check payable to: The LifeWorks Group, 1850 Lee Road, Suite 250, Winter Park, FL32789 or
* Email this registration form with your credit/debit card information to: Sola Thompson at sola@lifeworksgroup.org or
* Fax directly to: 407-647-8874 or
* Call us at 407-647-7005 to make a payment over the phone
Credit card number__________________________________________
Expiration date ___________ CVV code _________ Zip code for billing address of credit card ___________
Refund and cancellation policy: Full refund minus $35 processing fee if notice is given 10 days before workshop.
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