Event Registration

Please complete the form to register for this event.

Event: *

Select the event you are registering for - you may attend more than one! Just complete a separate registration for each event.

Your Contact Information

First Name: *

Last Name: *

Job Title: *

Your Job Role: *

Email: *

If you are here as a clinician or professional, please provide your work (i.e. agency email) and not a personal email (i.e. Gmail, Yahoo, etc.).

Phone: *

Organization Information

Organization Type:

Organization Name:

Organization’s Mailing Address:

City:

ZIP:

Additional Information

Receive CEU Credits? *

Yes

License Number:

Please provide your license number (10 digits only) if you wish to receive CEU credits.

Population Served:

Have you attended a previous FASD training? *

Yes

Comments/Special Requests:

Optional: please let us know if you have any special requests.