New Class Registration

Class: OPTIONS 553 Training

Class Registrant Information

The "Registrant" information below *MUST* be completed for the student - providing information specific to the person attending the training. The Email address must be unique for the Registrant. (ALL fields are required)

Registrant Email: *
Confirm Registrant Email: *
First Name: *
Last Name: *
One agency per registration. For additional Sponsoring agencies, call Pro-ACT, Inc at 909-758-0322. For addresses outside the US or Canada, call Pro-ACT, Inc at 909-758-0322.
Agency Name: *
Position: *
Secondary Email:
Home Address: *
City: *
State: *	--Select a State--Alberta, CanadaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingIncheon, South KoreaSao Paulo, Brazil
Zip: *
Day Phone: *
Cell Phone: *
* - required field

Sponsor Info

MUST READ: Your Sponsor is a person inside your agency/organization who has oversight of your work and the official authorization to execute an Agreement between your organization and Pro-ACT, Inc. Because your Sponsor will receive a copy of the In-service Instructor Agreement via DocuSign, their correct and valid email address must be included. For Instructor-owned entities, provide the same name and email address as for Instructor. Participation in class requires the Agreement be correctly completed by both parties.

Sponsor First Name: *
Sponsor Last Name: *
Sponsor Job Title: *
Sponsor Email: *

Payment

While payment may be made by check, your class registration is not reserved and you will not have access to additional class information until payment in-full is received. Payment by credit card may be made on the following page and confirms your registration immediately.

Refunds and Dismissal Policy Review and Acceptance

The Pro-ACT, Inc. Refunds and Dismissal Policy may be reviewed by clicking HERE.

By checking this box , I certify that I have read and understand the Pro-ACT, Inc. Refunds and Dismissal Policy.

Confirmation of Sponsoring Agency Role

Participation in a Pro-ACT In-service Instructor training class requires that the individual is either employed as a W-2 employee by or owns and operates an agency in which Pro-ACT training is or will be implemented. The agency then serves as the Sponsoring agency.

By checking this box , I confirm that I am employed by the organization identified as my Sponsoring agency.
-or-
By checking this box , I confirm that I own and operate a business that will serve as my Sponsoring agency.

Submit Registration

Press the buttom below to submit the Registration data. You will be directed to the Payment page, where you will complete the payment transaction. You will receive an Email to confirm that we've received your information, along with further instructions.