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| <p><strong>Print and fax a copy of this form to Attn: Sherri Lincoln, 763-427-7841, or register on line</strong></p> |
| <p>(One form must be completed for each attendee)</p> |
| <p><strong>Registration Form</strong></p> |
| <p><strong>U.S. Department of Education, Grants to Reduce Alcohol Abuse</strong></p> |
| <p><strong>NATIONAL MODEL PROGRAMS TRAINING INSTITUTE</strong></p> |
| <p><strong>October 31-November 4, 2005 • Chicago, Illinois</strong></p> |
| <p>Individuals registering who are not U.S. Department of Education GRAA grantees will be required to pay a $50 per day registration fee. Central CAPT will invoice you. Please write your purchase order number below.</p> |
| <p><strong>(please print or type)</strong></p> |
| <p>Name </p> |
| <p>Last Name First Name Preferred Name for Badge</p> |
| <p>Organization </p> |
| <p>Address </p> |
| <p>Street City State Zip</p> |
| <p>Phone (Work) Fax E-mail </p> |
| <p>Purchase Order Number: ____________________________</p> |
| <p><strong>Participants requiring special arrangements (i.e., large print, sign interpreters, etc.) should contact Sherri Lincoln at 800-782-1878, ext. 123. Requests must be submitted by October 21, 2005, for us to meet your needs.</strong></p> |
| <p><strong>Special Dietary Requirements:</strong> Vegetarian Vegan Kosher</p> |
| <p><strong>Please check the appropriate model program you are registering for:</strong></p> |
| <p>Creating Lasting Family Connections (October 31 through November 4)</p> |
| <p>Class Action (November 2 or November 3)</p> |
| <p>Project SUCCESS (November 1 through November 3)</p> |
| <p>LifeSkills (November 1 through November 2)</p> |
| <p>Communities Mobilizing for Change Against Alcohol (November 2) </p> |
| <p>Project Northland (November 1 through November 3)</p> |
| <p>There are no more openings for the Reconnecting Youth training (November 1 through November 4). Registrations are filled.</p> |
| <p><strong>This form registers you for the National Training Institute only (not hotel reservations). You will receive confirmation of your training registration by mail. Training participants are responsible for purchasing their own training materials, and bringing them to the training. Upon confirmation of registration, information to order the materials will be communicated. </strong></p> |
| <p><strong>Please make your hotel reservations by calling the Renaissance Chicago O’Hare Hotel, 8500 West Bryn Mawr Avenue, Chicago, IL 60631, phone 1-800-919-4803. Reference “National Training Institute” when you make your reservations, for the rate of $129/night +tax. The special room rate expires October 21, 2005, or when a maximum room block number is met. Make your reservations as soon as possible, to assure space in the room block. Hotel Web site is marriott.com/property/propertypage/CHIBR.</strong></p> |
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