Registration Form

Please complete then Fax to: DR. PENNINGTON at 866-553-5231 or mail to the address below.

I WOULD LIKE TO REGISTER FOR THE _________________________________ GROUP

THAT IS HELD ON _______________________________DATES.

MY CHILD'S NAME IS___________________________________ AGE_________

ADDRESS____________________________________________
ADDRESS____________________________________________

PARENTS' NAMES: ____________________________________________________________

WORK PH.________________________ HOME PH. ________________________

ENCLOSED IS MY DEPOSIT TO AYVP-LTD FOR $270 TO HOLD MY PLACE.

NOTE: Cancellations not made more than 30 days in advance forfeit 50% of the deposit.
Cancellations made less than 15 days prior to the event forfeit 100% of the deposit.

MAIL TO:

Dr. Yvonne Pennington
2760 Timberline Road
Marietta GA 30062

VIA FAX # 866-553-5231

Dr. Pennington accepts Visa and Mastercard:
Please check which card you wish to use:

VISA______ M/C______ Card #__________-___________-___________-___________

3-Digit CID# on back: _______ EXP. DATE: ____________

NAME ON CARD:
____________________________________________

SIGNATURE:
____________________________________________ DATE:____________________

Yvonne V. Pennington, Ph.D.
Phone: 404-255-6967

yvonne@ypsychology.com