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Tri-State Collaborative April 2017 CBT Workshop Registration

1.Practice Name(Required.)
2.Please provide your first and last name.(Required.)
3.Please provide an email address where we can contact you if we have questions.(Required.)
4.I understand that my practice will be invoiced $35 per attendee.(Required.)
5.Please provide the first and last name of the billing contact for your practice.(Required.)
6.Please provide the email address for the billing contact at your practice.(Required.)
7.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.(Required.)
8.Please provide the primary role that each attendee serves within your practice.(Required.)
Primary Role in Practice
Attendee 1
Attendee 2
Attendee 3
Attendee 4
Attendee 5
Attendee 6
Attendee 7
Attendee 8
Attendee 9
Attendee 10
9.Please provide an email address corresponding to each attendee above for the pre-event survey and post-event evaluation.(Required.)
10.Do any attendees from your practice have dietary restrictions? Please check all that apply.(Required.)
Food allergy
Gluten-free
Halal
Kosher
Vegan
Vegetarian
Other
None
Attendee 1
Attendee 2
Attendee 3
Attendee 4
Attendee 5
Attendee 6
Attendee 7
Attendee 8
Attendee 9
Attendee 10
11.If anyone from your practice requires accommodations, please describe.