JavaScript must be enabled in your web browser before using this form.
You can enable now JavaScript via the Tools/Options menu of your web browser.
After doing so, select the View/Reload or View/Refresh menu item to clear this message.
Registration
Please fill out the form completely. Your confirmation and invoice will be mailed to you shortly after we receive your registration form. Please note - when registering for a training session, you may only register for one training at a time. To register for multiple trainings or multiple participants, you must fill out multiple forms. Thank you.
Please provide the following (*required)
First Name*
Last Name*
Title*
Company*
Address*
City*
State*
Zip Code*
Phone*
Fax
Email*
Training

1.
Which training are you registering for?
ToP Strategic Planning, July 23-24, 2009, Oneida Community Education Center, 2632 S. Packerland Dr. Green Bay
Discovery Dating Teacher Training, Aug. 20-21, 2009, Oneida Community Education Center, 2632 S. Packerland Dr. Green Bay
ToP Group Facilitation Methods, Oct. 15-16, 2009, Oneida Community Education Center, 2632 S. Packerland Dr. Green Bay

2.
What level are you registering at?
First-time trainee for ToP Strategic Planning $675
Refresher trainee for ToP Strategic Planning $100
First-time trainee for Discovery Dating $375
Refresher trainee for Discovery Dating $100
First time trainee for ToP Group Facilitation Methods $675
Refresher trainee for ToP Group Facilitation Methods $100

3.
Would you like to order any of the following Discovery Dating materials?
(Select all that apply.)
$114 Dreams and Goals Chart kit (15 charts and 15 pens)
$249.95 Key Encounter Kit (40 cards, 80 sheets, camera, film, instructions and tote bag)
$351.75 Discovery Dating Classroom Accessory Kit (15 card sets, 20 tri-markers & pens, 25 pyramid & diary sheets, tote bag
$1080 Discovery Dating Teacher Kit (Classroom Accessory Kit plus 15 student kits & Dreams & Goals charts & Teacher's Manual)
Demographics

4.
What is your age?

5.
What is your education? Please list your highest degree and major if applicable.
(Select two.)
High school diploma
Certificate
Some college
Associates Degree
Bachelors Degree
Post graduate work
Masters Degree
Doctorate
Major:

6.
How many years of experience do you have working with youth?

7.
In what capacity?
(Hold down the CTRL key and select all that apply.)
Questions for grant reporting purposes
These questions provide demographic information we are required to collect for our grant. We appreciate your time in answering these questions. Thank you.
8.
Do you work for or fall under any of the following categories?
(Hold down the CTRL key and select all that apply.)

9.
Do any of these categories apply to YOU?
(Hold down the CTRL key and select all that apply.)

10.
What is your gender?
Male
Female
Me

11.
What is your ethnicity?
(Hold down the CTRL key and select all that apply.)

Created with SurveyGold online surveys - www.surveygold.com