Due September 16, 2005

Check one:

• Trained Mediator
  
• Non-Mediator
  

  Name: _____________________________________________________________________

  Title: _____________________________________________________________________

  Organization: _______________________________________________________________

  Address: ___________________________________________________________________

  City/State/Zip: _____________________________________________________________

  Phone: ____________________________________________

  Fax: _________________________________________________

  Email: ________________________________________________

  
  
  
  

  Please provide (or attach) a brief description of your background and experience in mediation/aging/guardianship.

  
  _____________________________________________________________________
  _____________________________________________________________________
  _____________________________________________________________________
  _____________________________________________________________________
  _____________________________________________________________________
  
  
  
  

  If you have special accommodation or dietary needs, please list below.

  
  _____________________________________________________________________
  _____________________________________________________________________
  _____________________________________________________________________
  
  
  
  

  Registration Fees:

  $450 fee enclosed (rec'd by 9/16/05 deadline)

  $500 fee enclosed (rec'd after 9/16/05 deadline)

  
  
  
  

  Please mail form and payment (payable to The Center for Social Gerontology) to:
  

  TCSG
  2307 Shelby Avenue
  Ann Arbor, MI 48103

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