Program Course Registration

I am registering for the course:
Select a Course ---> Developing the Dream: 3/24/2010

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First:
Last:
Address:
City:
State: Select a State or Province ---> Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick Newfoundland New Hampshire New Jersey New Mexico New York North Carolina North Dakota Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon
Zip:
Daytime Phone:
Evening Phone:
Email Address:
Fax Number:
Profession:
Program:
Tribal Affiliation:

Do you have a DS exemption?:
Yes
No

We are offering CEUs for the following disciplines: Physical Therapy, Occupational Therapy, Speech Language Pathology and Counseling/Social Work. Please select the disciplines for which you would like to receive CEUs.

A $20 fee for CEUs is to be paid at the training. Please make checks payable to: UNM/CDD.
Physical Therapy
Occupational Therapy
Speech Language Pathology
Counseling/Social Work

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