World Elder Abuse Awareness Day Seminar Organization Registration Form

WORLD ELDER ABUSE AWARENESS DAY SEMINAR ORGANIZATION REGISTRATION FORM EVENT INFORMATION: DATE - MONDAY, JUNE 15, 2009 TIME 7:30 AM – 4:00 PM NORTH SHORE HARBOR CENTER LOCATION 100 HARBOR CENTER BLVD. SLIDELL, LA 70461 THIS FORM IS FOR ORGANIZATIONS SENDING FIVE OR MORE EMPLOYEES TO THIS EVENT. PLEASE COMPLETE ALL REQUESTED ORGANIZATION INFORMATION, INCLUDING THE NAME, PHONE, AND E-MAIL ADDRESS OF THE CONTACT PERSON. REGISTRATION FEES: CASH OR CHECK ONLY BASIC1 PROFESSIONAL

2

TIMELY

LATE

ON/BEFORE MAY 23RD

MAY 23JUNE 10

ONSITE

$27.00

$36.00

$45.00

$45.00

$58.50

$67.50

1

BASIC – THIS LEVEL IS NOT ELIGIBLE FOR CONTINUING EDUCATION CREDIT PROFESSIONAL – THIS LEVEL IS APPLYING FOR CONTINUING EDUCATION CREDIT FROM THE LOUISIANA DISTRICT ATTORNEYS ASSOCIATION (APPROVAL PENDING) OR THE LOUISIANA CHAPTER OF THE NATIONAL ASSOCIATION OF SOCIAL WORKERS (THIS PROGRAM WAS APPROVED FOR 6.0 GENERAL CONTACT HOUR(S) OF CONTINUING EDUCATION CREDIT BY THE NATIONAL ASSOCIATION OF SOCIAL WORKERS—LOUISIANA CHAPTER AS AUTHORIZED BY THE LOUISIANA STATE BOARD OF SOCIAL WORK EXAMINERS). NOTE: IT IS THE RESPONSIBILITY OF THE ATTENDEE TO KNOW IF S/HE IS ELIGIBLE FOR CONTINUING EDUCATION CREDIT. REFUNDS WILL NOT BE AUTHORIZED IF THE ATTENDEE ERRS BY APPLYING WHEN INELIGIBLE. 2

REGISTRATIONS POSTMARKED ON OR BEFORE MAY 23RD WILL BE TIMELY. REGISTRATIONS POSTMARKED FROM MAY 24TH TO JUNE 10TH WILL BE CONSIDERED LATE. ALL REGISTRATIONS POSTMARKED AFTER JUNE 10TH WILL BE ON SITE REGISTRATIONS. CANCELLATION POLICY: CANCELLATIONS RECEIVED BEFORE MAY 1, 2009 WILL BE REFUNDED IN FULL. REQUESTS RECEIVED MAY 1-MAY 23 WILL RECEIVE A 50% REFUND. THERE WILL BE NO REFUNDS FOR CANCELLATIONS RECEIVED ON OR AFTER MAY 24, 2009.

REGISTRANT INFORMATION COMPLETE THE ORGANIZATION INFORMATION BELOW, AND LIST EMPLOYEES ON THE ATTACHED PAGE. PLEASE PRINT ORGANIZATION: ________________________________________________________________________________ MAILING ADDRESS: _____________________________________________________________________________ STREET OR PO BOX

_____________________________________________________

_______ _______________________

CITY

STATE

ZIP CODE

CONTACT NAME: ________________________________________________________________________ CONTACT PHONE: _____________________ E-MAIL: ___________________________________________ TOTAL NUMBER OF EMPLOYEES ATTENDING: _________

AMOUNT ENCLOSED: $_______________

Mail to: St. Tammany SALT Council PO Box 596 Mandeville, LA 70470-0596 ST. TAMMANY SALT COUNCIL

PHONE: 985-809-5450

E-MAIL: [email protected]

REGISTRATION SUPPLEMENT PLEASE PRINT

EMPLOYEE #1: ___________________________________________________ E-MAIL: ___________________________________ PHONE: _______________

EMPLOYEE #2: ___________________________________________________ E-MAIL: ___________________________________ PHONE: _______________

EMPLOYEE #3: ___________________________________________________ E-MAIL: ___________________________________ PHONE: _______________

EMPLOYEE #4: ___________________________________________________ E-MAIL: ___________________________________ PHONE: _______________

EMPLOYEE #5: ___________________________________________________ E-MAIL: ___________________________________ PHONE: _______________

EMPLOYEE #6: ___________________________________________________ E-MAIL: ___________________________________ PHONE: _______________

EMPLOYEE #7: ___________________________________________________ E-MAIL: ___________________________________ PHONE: _______________

EMPLOYEE #8: ___________________________________________________ E-MAIL: ___________________________________ PHONE: _______________

EMPLOYEE #9: ___________________________________________________ E-MAIL: ___________________________________ PHONE: _______________

EMPLOYEE #10: __________________________________________________ E-MAIL: ___________________________________ PHONE: _______________

ST. TAMMANY SALT COUNCIL

PHONE: 985-809-5450

E-MAIL: [email protected]