2026 Jodie Williams Professional Learning ConferenceRegistrant Agreement & Breakout Session Selection Survey

Registrant Information:(Required.)

Full Name:

Email Address (conference information will be sent to this address):

Licensure/Certification Type
(ex: OT/PT/PTA):

County of Employment:

Registrant Agreement (please check off all statements)(Required.)

I give permission to release my contact information and attendance records for this course to Howard Community College, the Maryland State Steering Committee for Occupational and Physical Therapy School-based Programs, the Maryland State Department of Education and the appropriate accrediting bodies for CEUs.

I understand that I must be logged on for the entire conference and must complete, at the designated times, the required pre- and post-tests in order to receive a CEU certificate.

I certify that I am the person described in this form and that the information presented is correct to the best of my knowledge: This certification constitutes my electronic signature.

2026 Jodie Williams Professional Learning Conference
Registrant Agreement & Breakout Session Selection

Friday, October 16, 2026