Children Exposed to Violence
Trauma-Focused Cognitive Behavioral Therapy
A 2-Day Intensive Training

CEV TF-CBT 2 Day Intensive Training

CHILDREN EXPOSED TO VIOLENCE
Trauma-Focused Cognitive Behavioral Therapy
2-Day Intensive Training

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* Contact Information

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First Name:

Last Name:

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Job Title:

Agency:

Address 1:

Address 2:

City:

**State:

Zip:

Phone (xxx.xxx.xxxx):

Extension:

TTY(xxx.xxx.xxxx):

Fax (xxx.xxx.xxxx):

E-mail:

Cell Phone Number:

Emergency Contact Name:

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**If you are from South Carolina please contact the meeting organizers, as there are specific regional opportunities available for you.

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* Please describe which best describes you:


Is your community a federal grantee? If so, please select which type.	Is your community a federal grantee? If so, please select which type. menu

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* Please assure that all information above is correct. It will be used for all meeting materials (e.g., name badges, table tents, the participant contact list, etc.). Do you give us permission to share your full contact information with other meeting participants.

Yes

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*
For purposes of selecting your travel dates and booking your flights, please assume that the training will start at 9AM and end at 5PM ET daily (November 8-9, 2012). The arrival and departure information that you provide below will be used to register and hold your hotel room under the Alliance of Local Service Organization’s (ALSO’s) rooming list. (See below for hotel rates and details.)

Arrival:

Date

Time

AM/PM

Departure:

Date

Time

AM/PM

Lodging & Meeting Location

The Trauma-Focused Cognitive Behavioral Therapy Training will be held at the Hyatt Place Charleston Airport/Convention Center Hotel at 3234 W. Montague Avenue North Charleston, SC 29418. Although there is no fee to attend, participants are responsible for their own travel expenses (e.g., transportation, food, lodging, etc.). Please note that food will not be provided during the training sessions, but complimentary breakfast will be provided by the hotel.

ALSO has negotiated sleeping room rates of $119 per single occupancy and $135 per double occupancy. These rates are only guaranteed for Wednesday-Thursday nights (i.e., check-in on November 7 and check-out on November 9). Please note that these rates do not include tax. Participants needing to check-in before, or check-out after, these dates should contact ALSO to confirm the rates for any additional nights (we have a limited number of rooms guaranteed for Friday night, November 10th). ALSO will use the arrival and departure dates stated above to add you to its rooming list and will send you a hotel confirmation number prior to the training. The hotel will ask for a credit card at check-in to cover your room and incidentals.

We value access and safety and strive to make our meetings accessible and welcoming to all participants. Please fill out the following information to help us provide accommodations that give everyone an opportunity to fully participate in this meeting.

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* Please select any accommodations you require for the meeting. In order for services to be as appropriate as possible, please be as specific as possible. Every effort will be made to accommodate requests made in advance. On-site requests cannot be guaranteed.

None required

American Sign Language Interpreter

Cued Speech

Electronic copies of meeting materials in advance

Electronic text file of materials (available at the meeting)

Materials in Braille

Materials in font over 14 pt (please indicate the font size in the "other" box)

Signed English

Simple Language Program

Simultaneous Communication

Wheelchair access

Oral/English

Other (please specify)

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* Please specify any special hotel accommodations you require. In order for services to be as appropriate as possible, please be as specific as possible. Every effort will be made to accommodate requests made in advance. On-site requests cannot be guaranteed.

ADA Room with Roll-In Shower

ADA Room with Tub and Shower

Chemical Free Room

Room Accessible for Deaf/Hard-of-Hearing

Room Preparation for Infant (i.e. - a crib)

None of the above

If necessary, please provide further details describing your preferred accomodations:

If you have a disability that requires a Personal Care Attendant (PCA) or Personal Assistant (PA) accompany you on your travel, please contact LaTanya Lane at 773.235.5705 ext 31 or tlane@also-chicago.org to discuss accommodations.

Every effort will be made to ensure access to this meeting; please allow us sufficient time to meet your request for auxiliary aids and services by responding no later than October 17, 2012. Please contact us if you need referrals for assistance outside of the meeting. Please contact LaTanya Lane with any questions.

Transportation

The hotel is approximately 2 miles from the Charleston airport. The Hyatt Place offers complimentary transportation to and from the hotel. Please call the Hyatt Place for shuttle service once you arrive at 843-302-8600. If you prefer to take a taxi, rides to and from the hotel are estimated to be around $4.00 per trip available through Yellow Cab of Charleston.

Before pressing the “Done” button at the bottom of the survey, please print the page for your records as you will not be able to access the page once you have pressed the “Done” button. The CEV Trauma Focused Cognitive Behavioral Therapy Training on the Alliance of Local Service Organization web page will be updated to reflect the most current information about this meeting and you will be notified via email about these updates.

Thank you for taking the time to complete this registration form!
If you have any questions please contact LaTanya Lane at 773-235-5705 extension 31.
You can also send questions or comments to:
tlane@also-chicago.org.