Fatherhood Workshop

2006 Registration Form
Please register me for the workshop indicated.

 

Working With Fathers: Building Skills For Practitioners (3-day)

 

Dates

Locations/Cities

__February 15 - 17
__March 8 - 10
__April 18 - 20 

__May 16 - 18

__July 26 - 27
__August 22 - 24
__September 19 - 21
__October 17 - 19
__November 7 - 9
__December 5 - 7

Washington , DC
Washington , DC
Washington , DC
Washington , DC
Washington , DC

Washington , DC
Washington, DC 
Washington, DC
Washington, DC
Washington, DC

Helping Fathers Develop And Maintain Positive Relationships (1-day)

Dates

Locations/Cities

To Be Determined

To Be Determined

 

 

 

Please Print/Type

 

Name: Mr./Ms._________________________________________________
Title: _________________________________________________________
Organization: __________________________________________________
Street Address: ________________________________________________
City : _________________________________________________________
State : _______________________ Zip: _____________________________
Phone: ( ) _____________________ Fax: ( ) _________________________

E-mail:_______________________

Name as you would like it on name badge:
First:_________________________________________________________ Last:_________________________________________________________

Name as you would like it on your certificate:
First:_________________________________________________________
Last _________________________________________________________

Lunch Preference: __Regular __Vegetarian
How did you hear about this workshop? ______________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

For Office Use Only: __________________________________________
PO #_________________________ CK# _________________________
CFRM________________________DB __________________________

Please Check All of the Following That Apply To Your Agency:

 

__Currently Working with Fathers
__Community-based Nonprofit Organization
__Planning to Start a Program for Fathers
__Federal, State or Local Government
__Currently Working with Mothers
__Voluntary Community Service

 

Please mail or fax registration form to:
NPCL
Attention: Training Department

1875 I Street, NW
Suite 5 00
Washington , D.C. 20036
Phone: (202) 429-2027

Fax: (202) 429-2028

 

 

Please Check the Box That Best Describes Your Agency:

 

 

__Youth Serving Organizations
__Early Childhood Education
__Employment Training
__Criminal Justice
__Mental Health

__Education
__Teen Parenting
__Health
__Child Support Enforcement

Other: ________________________________________________________

 

Which of the Following Most Closely Describes Your Position in Your Organization?

__Administrator
__Educator
__Counselor/Case Manager
__Employment Specialist

__Group Worker/Facilitator
__Outreach Worker
__Case Worker

Other: _________________________________________________________

 

What Are Your Primary Reasons For Attending This Workshop? ______________________________________________________________ ______________________________________________________________ ______________________________________________________________

 

If You Are Currently Working With Fathers, Briefly Describe
Your Program or Attach your Program Brochure and
Other Relevant Information ______________________________________ ______________________________________________________________ ______________________________________________________________

 

Registration Type (Check One)

___3-day $600
___1-day $250
___3-day and 1-day combination $800

 

Indicate Payment Method:

 

__Check enclosed (payable to NPCL)
__MasterCard
__American Express

__Company Purchase Order
__Visa

Card# ________________________________________________________

 

Card Exp. _____________________________________________________

 

_____________________________________________________________
Cardholder's Signature

 

Please mail or fax registration form to:
NPCL
Training Department

1875 I Street, NW

 

 

Suite 500
  Washington , D.C. 20036
Phone: (202) 429-2027 * Fax: (202) 429-2028