Professional Education Lectures Registration

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* 1. Your Contact Information

First Name *

Last Name *

Street Address *

City *

State *

Zip *

County

Phone: (xxx) yyy-zzzz

e-mail address

If employed, please provide position/title, employer.

Your contact information will be used to send you monthly email and periodic postal service notices of SCOSA events.

Please remember to click SUBMIT at the bottom of the page so that your information will be recorded.

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* 2. My reason(s) for completing this form today: (Check all that apply)

Add me to SCOSA mailing list
I want to receive SCOSA E-News, occasional e-mail and print updates/announcements.

Register for upcoming programs: details below

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* 3. License number REQUIRED:

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* 4. Register for Upcoming Professional Lectures:
Please enter your name(s) in the box adjacent to each event you wish to attend. Also, please mark your calendar - we do not e-mail confirmations or reminders. Please check "Professional Education" at www.stockton.edu/scosa or email Gina.Maguire@stockton.edu.

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* 5. Basic Information about you:
SCOSA programs are free unless otherwise noted. We are partially funded under the Older Americans Act of 1965, as amended, which requires us to collect basic demographic information from you. Your voluntary answers to the following questions help us determine eligibility for program funding and to secure future funding. Your answers will be kept strictly confidential. Thank you!

We are also required to inform you that we gratefully accept donations for services provided. Donations will support ongoing programming. To donate go to www.stockton.edu/scosa and scroll to the bottom (Supporting SCOSA) section.

Age

If you have any general questions about SCOSA, please email SCOSA@stockton.edu.

If you have any specific questions about any of the Professional Education programs, please email Gina.Maguire@stockton.edu.