Sunday, September 7th, 2008

Registration Form

*Required fields are marked with an asterisk.

Registrant Information

Prefix:

First Name: *

Last Name: *

Suffix:

Job title or position: *

Registering as: *

Grantee Name:

Organization Name (if different than Grantee Name):

School building where you work, if applicable:

Street Address where you receive business mail: *

Street Address 2nd Line:

City: *

State: *

Zip Code: *

Business Phone: *

( ) -

Ext

Business FAX: *

( ) -

Business Email Address: *

County: *		Intermediate Unit (required if you are registering from a school):

Professional Development/Continuing Education Credits
Please check if you are interested in receiving Act 48 credits
Please check if you are interested in obtaining a certificate of attendance (LSW Continuing Education)

Tuesday, April 17th
Will you be attending the training on April 17th?* yes no

Please indicate which meals you will attend:
Lunch (Note: Please indicate any special meal accommodations below.)
Reception

Wednesday, April 18th
Will you be attending the training on April 18th?* yes no

Pre-selection is not required for Thursday's workshops.

Please indicate which meals you will attend:
Continental Breakfast Lunch (Note: Please indicate any special meal accommodations below.)

Special Meal Accommodations
The meals listed above will be provided. Please indicate any special meal accommodations.

Vegetarian
Other special dietary needs:



ADA Special Needs Accommodations Participation by all individuals is encouraged. Advance notice of any special needs will help us provide better service. Please notify us of your needs by entering them below. I have special needs in order to attend ADA special needs:

Lodging
Participants are responsible for their own travel and lodging arrangements. Please refer to the training information page for special hotel rates and contact information.

Register Early - Deadline for registration is March 30, 2007 or until registration is full.

When you click the submit button, you will receive an email confirming receipt of your registration request and a plain text copy of the information you submitted. The email will be sent to the business email address listed above.