2026 Advanced Training Registration Form

2026 COLLABORATIVE ADVANCED TRAINING REGISTRATION FORM
Full Name*

First NameLast Name
Organization*
Profession:*
E-mail*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are You A Current Member of CPIM?

YesNo
PAYMENT: To submit your payment, please use one of the following payment links:
- EARLY BIRD ($375) - Pay Early Bird Rate Now (valid through 3/24/26)
- REGULAR RATE ($450) - Pay Regular Rate Now (effective 3/25/26)
CANCELLATION POLICY:

30 days (75% refund), 14 days (50% refund), 7 days (25% refund)

We regret that we cannot honor refund requests within the week before the workshop.
EMAIL AIME VANDERMEER (admin@collaborativepracticemi.org) WITH ANY SPECIAL ARRANGEMENTS OR DIETARY RESTRICTIONS
Should be Empty:

2026 COLLABORATIVE ADVANCED TRAINING REGISTRATION FORM