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WORLD ELDER ABUSE AWARENESS DAY

SEMINAR
INDIVIDUAL REGISTRATION FORM
ORGANIZATIONS SENDING 5 OR MORE EMPLOYEES SHOULD USE THE ORGANIZATION REGISTRATION FORM
EVENT INFORMATION:
DATE - TUESDAY, JUNE 15, 2010
TIME - 8:00 AM – 4:30 PM
LOCATION - NORTH SHORE HARBOR CENTER
100 HARBOR CENTER BLVD.
SLIDELL, LA 70461
REQUESTS TO CERTIFY A MINIMUM OF FIVE (5) HOURS OF CONTINUING EDUCATION CREDIT ARE PENDING WITH NASW-LA, THE LA BAR ASSOCIATION, LABENFA,
AND THE PROFESSIONAL COUNSELORS ASSOCIATION OF LA. WHEN CONFIRMATION IS RECEIVED, YOU WILL BE NOTIFIED. PLEASE CONTACT THE SALT COUNCIL IF
YOU HAVE ANY QUESTIONS.

REGISTRATION FEES*:
TIMELY LATE

ON/BEFORE MAY 21ST MAY 21-JUNE 10 AFTER JUNE 10 OR ON-SITE


1
BASIC $40.00 $50.00 $60.00
2
PROFESSIONAL $65.00 $75.00 $90.00
1
BASIC – THIS LEVEL WILL NOT RECEIVE CONTINUING EDUCATION CREDIT
2
PROFESSIONAL – CONTINUING EDUCATION CREDIT HAS BEEN APPROVED AS SHOWN BELOW ON BEHALF OF: LA CHAPTER, NASW; LA STATE BAR ASSOCIATION;
LA COUNSELING ASSOCIATION; LA BOARD OF EXAMINERS OF NURSING FACILITY ADMINISTRATORS.
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.
REGISTRATIONS POSTMARKED ON OR BEFORE MAY 21ST WILL BE TIMELY. REGISTRATIONS POSTMARKED FROM MAY
21ST TO JUNE 10TH WILL BE CONSIDERED LATE. ALL REGISTRATIONS POSTMARKED AFTER JUNE 10TH WILL BE TREATED
AS ON SITE REGISTRATIONS.
CANCELLATION POLICY: CANCELLATIONS POSTMARKED BEFORE MAY 10, 2010 WILL BE REFUNDED IN FULL. REQUESTS POSTMARKED MAY 11-JUNE 1
WILL RECEIVE A 50% REFUND. THERE WILL BE NO REFUNDS FOR CANCELLATIONS POSTMARKED ON OR AFTER JUNE 1, 2010.
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

COMPLETE THE INFORMATION BELOW AND MAIL THE COMPLETED FORM WITH CHECK TO:

ST. TAMMANY SALT COUNCIL


PO BOX 596
MANDEVILLE, LA 70470-0596
CREDIT CARD PAYMENT IS AVAILABLE WITH ONLINE REGISTRATION. SEE WWW.STSALT.ORG.

BASIC (NO CE)


PROFESSIONAL:
Please check one NASW-LA
box for the type LA BAR ASSOC.
of registration
LCA
LABENFA
REGISTRANT INFORMATION

NAME: _____________________________________________________________________________

MAILING ADDRESS: ____________________________________________________________________


STREET OR PO BOX

CITY: ________________________________________STATE: _______ ZIP CODE: ________________

CONTACT PHONE: _________________________ E-MAIL: _________________________________


ST. TAMMANY SALT COUNCIL PHONE: 985-809-5450 E-MAIL: WEAAD@STSALT.ORG