Online Registration Form

* Please fill out one form for each registrant.

INFORMATION
First Name:
MI:
Last Name:
Email:
Agency:
Phone:
Position/Title:
Business Address:
City:
State:
Zip Code:

Select breakout session number (see program). Please select first and second option. (Click on drop-down list.)

	First Option	Second Option
1:20 - 2:00 pm
2:10 - 2:50 pm

Please indicate the type of continuing education units you intent to seek:

Social Workers
Counselors
Psychologists
Teachers
Nurses
Law Enforcement Professional

SPECIAL NEEDS

If you require any auxiliary aids or services identified in the American with Disabilities Act, please indicate assistance required:

PAYMENT INFORMATION

Early Registration (March 26 - April 24): $80
Early Registration and CEUs: $90
Early Registration (Students only) $40
Late Registration (April 25 - May 1): $100
Late Registration and CEUs: $110
Late Registration (Students only) $40

For more information or questions, please contact Student Health Services at (956) 882-3896 or at shs.interns@utb.edu