Name ________________________________________________

Organization___________________________________________

Address ______________________________________________

City/ State ______________________________________

Zip ______________________________________________

Phone _______________________________________________

E-mail________________________________________________

GRPevent. A 50% refund will be given if the refund application

is received less than 5 business days before the event, minus the service and material charges. No request for

refund will be honored on the day of the event. In the case of a tragic emergency payment may be held over for

Send payment (check, credit card or money order) and form to:

Registration GRPA Member

Non-Member

CPSI Course

Exam

Total Due

No on-site registration will be accepted. If you require special accommodations, diet, or assistance with the exam,due to a disability, please attach a note to this application.

Playground Safety Inspector Cer tion Course & Exam

Geo

rgia

Rec

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ion

& P

ark

Ass

ocia

tion

1285

Par

ker R

oad

Cony

ers,

GA

300

94w

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mai

l: gr

pa@

grpa

.org

Who should attend...

This course is relevant to individuals affiliated with: Park & recreation departments

youth programsches, mosques & synagoguesruction trade unions

ractorsry schools

s, resorts, private clubs & amusement parks overnments

Trade schools

Staff who should attend:chitects rs

ractors rsrs

rs ayground equipment manufacturersayground operators & caretakers

works agers

GRPA/NRPA

Certified Playground SafetyInspector Course

and Exam

Sponsored by:

$415 $440

$110

September 17-19, 2018 Griffin, Georgia

GRPA, 1285 Parker Road, Conyers, GA 30094

Credit Card Form AttachedCancellation Policy

A Service charge of $15 for GRPA/NRPA members, $25 for non-members will be deducted from all refunds. A full

refund, less the service charge and $100 for materials, will

the next year or transferred to another course

CREDIT CARD AUTHORIZATION

Name on Credit Card: _____________________________________________________ Credit Card Billing Address: ________________________________________________

STREET

____________________ __________ ______________

CITY STATE ZIP CODE

Card #: ____________ ____________ ____________ ____________ Expiration Date: ________ __________ CVC Code: ___________________ Authorized Amount to be Charge: ____________________________________________ Email address to send receipt to: _____________________________________________

PLEASE NOTE: All credit card information is

shredded after cards are processed. GRPA does not keep any credit card information on file. This is in

compliance with Payment Card Industry Data Security Standards. (PCI DSS)