Tri-State Collaborative April 2017 Cognitive Behavioral Workshop Registration for CME

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* 1. Practice Name

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* 2. Please provide your first and last name.

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* 3. Please provide an email address where we can contact you if we have questions.

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* 4. Please list all attendees from your practice (including yourself, if applicable). Include first name, last name and credentials as they should appear on the name badges.

Attendee 1

Attendee 2

Attendee 3

Attendee 4

Attendee 5

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* 5. Please provide the primary role that each attendee serves within your practice.

	Primary Role in Practice
Attendee 1	Attendee 1 Primary Role in Practice menu
Attendee 2	Attendee 2 Primary Role in Practice menu
Attendee 3	Attendee 3 Primary Role in Practice menu
Attendee 4	Attendee 4 Primary Role in Practice menu
Attendee 5	Attendee 5 Primary Role in Practice menu

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* 6. Please provide an email address corresponding to each attendee above for the pre-event survey and post-event evaluation.

Attendee 1

Attendee 2

Attendee 3

Attendee 4

Attendee 5

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* 7. Do any attendees from your practice have dietary restrictions? Please check all that apply.

	Food allergy	Gluten-free	Halal	Kosher	Vegan	Vegetarian	Other	None
Attendee 1	Attendee 1 Food allergy	Attendee 1 Gluten-free	Attendee 1 Halal	Attendee 1 Kosher	Attendee 1 Vegan	Attendee 1 Vegetarian	Attendee 1 Other	Attendee 1 None
Attendee 2	Attendee 2 Food allergy	Attendee 2 Gluten-free	Attendee 2 Halal	Attendee 2 Kosher	Attendee 2 Vegan	Attendee 2 Vegetarian	Attendee 2 Other	Attendee 2 None
Attendee 3	Attendee 3 Food allergy	Attendee 3 Gluten-free	Attendee 3 Halal	Attendee 3 Kosher	Attendee 3 Vegan	Attendee 3 Vegetarian	Attendee 3 Other	Attendee 3 None
Attendee 4	Attendee 4 Food allergy	Attendee 4 Gluten-free	Attendee 4 Halal	Attendee 4 Kosher	Attendee 4 Vegan	Attendee 4 Vegetarian	Attendee 4 Other	Attendee 4 None
Attendee 5	Attendee 5 Food allergy	Attendee 5 Gluten-free	Attendee 5 Halal	Attendee 5 Kosher	Attendee 5 Vegan	Attendee 5 Vegetarian	Attendee 5 Other	Attendee 5 None

Please describe any food allergy or "other" restrictions.

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* 8. If anyone from your practice requires accommodations, please describe.

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* 9. Please confirm that you understand that there is a $75 charge per attendee.

Yes

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* 10. Please provide the following contact information for the person who will handle payment.

First and Last Name

Email Address

Phone Number

HOTEL ROOM RESERVATIONS:
Have you reserved your room? If you plan to stay overnight on Thursday, April 20th, reservations can be made until April 6, 2017. Call 877-814-2538 or visit http://bit.ly/04_2017_CollaborativeHousing.
The room block rate is $102 per night + 6% state tax and 5% local tax.