Date:            Thursday, June 1, 2006 Time:            5:30pm - 9:00pm Location:      1199SEIU Martin Luther King, Jr. Auditorium                       310 West 43rd Street (8th & 9th Avenues)                       New York City

THE IDENTIFICATION AND REPORTING OF CHILD ABUSE

AND MALTREATMENT

A Three-Hour Course

REGISTRATION FORM                                                              Please Print Information Clearly

___________________________________                 ___________________________________

First Name                                                                                                 Last Name

SS#: ________________________________                               _____________________________________                          (REQUIRED)                                                                            Job Title

Telephone: (         )  _________    - _____________           Home Telephone: (      )     _______ - ____________          

Cell Telephone: (      )  ______ - ____________             E Mail: ________________________________________

Home Address: _____________________________________________________________________________

City: _______________________________________      State: ______________ Zip Code: _______________

Employer:___________________________________________           Job Fax: (      )     _______ - ____________  

CHECK ONE

r   (a) FREE for 1199ers if you have been a part-time (Aat least three-fifths of a regular work week) or full-time

         employee for at least one year AND your employer contributes tot he 1199SEIU Traning and Upgrading Fund.  

r (b) FREE for HHC 1199ers (Dietitians, Pharmacists and Lab Techs).

r (c) $36 for others.  Make check or money order payable to the 1199SEIU Training & Upgrading

           Fund/Institute.

FAX your Registration Form to (212) 643-8795 or mail to:

1199SEIU Training & Upgrading Fund/Institute, P.O. Box 1016, New York, NY 10108.  

For further information, call 212-894-4390 or email us at institute@1199etjsp.org.

Refund and Cancellation Policy for Onsite Seminars

Registrants canceling must do so at least 48 hours befroe the program date to avoid a penalty.  A full refund will be given for cancellations received up to 7 days prior to the date of the program.  To cancel contact the Institute by fax (212-643-8795), telephone (212-894-4390) or e-mail institute@1199etjsp.org.