School-Based iECHO Registration Form

WNYCCCED

School-Based Project ECHO® Eating Disorders (SB ECHO® EDO)

Registration for TeleECHO

If you would like to participate in the School-Based Project ECHO® Eating Disorders clinics, please fill in the registration information on this form and click ‘Done’ at the bottom of the page.

You will receive confirmation of your registration and information about upcoming clinics.

If you wish, you may also print out the form and return it via:

Email: wnyccced@urmc.rochester.edu

Mail: Jim Witmer, Project Coordinator
Western NY CCCED
601 Elmwood Ave Box, SON
Rochester NY 14642

Yes, I wish to register for the WNYCCCED Project ECHO® EDO Clinics coordinated by the University of Rochester School of Nursing and available through a ZOOM platform.

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* 1. School / Organization Name

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* 2. Name

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* 3. Credentials (LMSW, NP, RN, MEd, etc.)

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* 4. Specialty / Practice Area / Subject Area

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* 5. Title / Role
e.g. Social Worker, Nurse, Teacher, etc.

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* 6. Organization Street Address

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* 7. City / State / Zip Code

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* 8. County

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* 9. Phone

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* 10. Login Phone
The phone number that you would use when logging into the echo sessions

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* 11. Email Address

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* 12. Your Website URL (If available)

If you know of other school-based professionals who may be interested in participating in these clinics, please forward them the information about registration or ask them to contact us directly. We appreciate your spreading the word about this valuable resource.

Project ECHO® Eating Disorders Clinics are currently eligible for social work continuing education units through the Center for Experiential Learning at the University of Rochester Medical Center. Currently, CEUs are provided at no cost to project participants. More information about applying for CEUs will be sent following receipt of this registration.

Please feel free to contact our Project Coordinator, Jim Witmer with any questions at:

Email: wnyccced@urmc.rochester.edu Phone: 585-275-2936

WNYCCCED is funded in part by NYS Department of Health Division of Chronic Disease Prevention Project ECHO URSON Registration 09.29.3016

Question Title

* 1. School / Organization Name

Question Title

* 2. Name

Question Title

* 3. Credentials (LMSW, NP, RN, MEd, etc.)

Question Title

* 4. Specialty / Practice Area / Subject Area

Question Title

* 5. Title / Role e.g. Social Worker, Nurse, Teacher, etc.

Question Title

* 6. Organization Street Address

Question Title

* 7. City / State / Zip Code

Question Title

* 8. County

Question Title

* 9. Phone

Question Title

* 10. Login PhoneThe phone number that you would use when logging into the echo sessions

Question Title

* 11. Email Address

Question Title

* 12. Your Website URL (If available)

* 5. Title / Role
e.g. Social Worker, Nurse, Teacher, etc.

* 10. Login Phone
The phone number that you would use when logging into the echo sessions