University of Medicine and Dentistry of New JerseyUniversity Behavioral HealthCare

Continuing Education External Training Calendar

September – December2009

Training and Consultation Resources:Offering high-quality professional development

training opportunities

Registration is required for all trainings.

Important Information Regarding Professional Contact HoursPlease note that participants may not be eligible for continuing education credits if they are not on time and present for the entire session and sign-in and sign-out. Partial credits will not be issued to participants arriving late or leaving early. Contact hour fee is only accepted with the contact hour request form which is to be mailed, with payment, after the program.

Training and Consultation Resources Team(732) 235-9282

Linda Karimi Clinician AdministratorSharon Eaton Program CoordinatorRobert Ford Training and Consultation SpecialistMaxine Feintuch Program Assistant

Mission StatementTraining and Consultation Resources is dedicated to providing evidence-based and best practice trainings to behavioral health care professionals that promote high quality care for the people of New Jersey.

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PROFESSIONAL CONFERENCES/LECTURES

PresentAn Evening with

Dr. Kay Redfield Jamison

Kay Redfield Jamison is professor of psychiatry at Johns Hopkins University School of Medicine and co-director of the Johns Hopkins Mood Disorders Center. She is the author of the national best sellers An Unquiet Mind and Night Falls Fast; coauthor of the standard medical text on manic-depressive (bipolar) illness; and the author or coauthor of more than one hundred scientific papers about mood disorders, creativity, and psychopharmacology.

Dr. Jamison will discuss mortality, grief, and loss, which she views from deep inside the experience in her newly published book Nothing Was the Same.

Perhaps no one but Kay Jamison – who combines the acute perceptions of a psychologist with writerly elegance and passion – could bring such a delicate touch to the subject of losing a spouse to cancer. Her husband, Richard Wyatt, a renowned scientist who battled severe dyslexia, became one of the foremost experts on schizophrenia. With characteristic honesty, Dr. Jamison describes his slow surrender to cancer, her own struggle with overpowering grief, and her efforts to distinguish grief from depression.

Date: Wednesday, September 30, 2009Time: 7:00 pm – 8:15 pm Lecture and Questions & Answers

8:15 pm – 9:30 pm book sale and signing by Dr. Redfield JamisonPlace: UMDNJ Medical School - Piscataway Campus

Main Lecture Hall 675 Hoes Lane Piscataway, NJ 08554

Program Fee: FREE Light Refreshments will be served

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Parking and Directions

Robert Wood Johnson Medical School Piscataway Campus Directions

675 Hoes Lane West

Piscataway, NJ 08854

From the South via the New Jersey Turnpike:

Take exit 9- New Brunswick to Route 18 North through New Brunswick and across the Raritan River. As you cross the bridge, stay in the right and take the River Road exit. Turn right at the end of the ramp onto River Road. Go half a mile north on River Rd. to the third light, and turn right on Hoes Lane West. Follow directions below from there.*

From the Garden State Parkway North or South, or From the North via the New Jersey Turnpike:

Take the GSP north to exit 127 or south to exit 129 to Route 440 West which becomes I-287 North; or the New Jersey Turnpike to exit 10 to I-287 North. Take I-287 to Exit 9, Bound Brook/Highland Park; turn left at the end of the exit onto River Road. At the fourth traffic light (about 3 miles) turn left onto Hoes Lane West. Follow directions below from Hoes Lane West.*

From Route 287 Southbound:

From the Exit 9 – Bound Brook/Highland Park exit, turn right at the end of the exit onto River Rd. At the third traffic light (about 3 miles) turn left onto Hoes Lane West. Follow directions below from there.*

From Route 287 Northbound:

From Exit 9 – Bound Brook/Highland Park, turn left at the end of the exit onto River Road. At the fourth traffic light (about 3 miles) turn left onto Hoes Lane West. Follow directions below from there.*

Mass Transit: Taxi service is available from the New Brunswick train station 3.5 miles to UMDNJ's Piscataway Campus.

*From Hoes Lane West to Visitor Parking:

Proceed about a mile to a sign for UMDNJ. Visitors can park in Lot B on the opposite side of Hoes Lane West from UMDNJ/RWJMS complex.

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UNIVERSITY BEHAVIORAL HEALTH CARE - BEHAVIORAL RESEARCH AND TRAINING INSTITUTE

TRAUMATIC LOSS COALITIONS FOR YOUTH and TRAINING AND CONSULTATION RESOURCES

Post Traumatic Stress Management Training Post Traumatic Stress Management Training and Psychological First Aidand Psychological First Aid

With Ethnocultural, Gender and Developmental SpecificityWith Ethnocultural, Gender and Developmental SpecificityTraumatic Loss Coalitions for Youth: School & Community Based Responders PTSM

Training

20 Hour Certificate CourseWITH

Robert D. Macy, PhD

When: Tuesday, Wednesday, Thursday: October 27, 28, 29, 2009

Where: The Imperia, 1714 Easton Avenue, Somerset, NJ 08873 (732-469-2522)http://www.theimperia.com

Cost: $325 - Includes Continental Breakfast, Lunch, and Course Manual and Materials

Time: 7:30 AM Registration and Continental Breakfast7:55 Day 1: Welcome8:00 Certificate Post Traumatic Stress Management Training (PTSM)

Day 1: PTSM History; Safety Structuring PTSM Response Team; Systems; NIMS; Diversity: Community Based Incident Command; 8 Core Actions of Psychological First Aid

Day 2: PTSM Orientations and Practice, Exposure Variables, Systematic Response Protocols

Day 3: PTSM Coping Groups, Self-Care; TLC – PTSM Incident Command

NOTE: DAY 3 TRAINING ENDS AT 12:15 PM ON FRIDAY. NO PROVIDED LUNCH.

10:00 15-Minute Morning Break 10:15 Continuation of Morning Programs for Day 1, 2, and 3 Respectively

12 NOON Lunch – INCLUDED IN THE REGISTRATION FEE FOR WEDNESDAY AND THURSDAY ONLY

12:30 PM Day 1: Theoretical Models; Continuum of Stress; Overview of PTSM Interventions Spectrum; Appraisal Recognition; Mass Disaster Setting; Group Diversity Factors (Age, Gender, Culture, Military, etc)

Day 2: Challenge Activities, PTSM Coping Group Process with Diversity Variables

3:00 15-Minute Afternoon Break3:15 Continuation of Afternoon Programs for Day 1 and 2 Respectively5:00 PM Adjournment

Program Goal: The goal of this training is to enable trainees to respond to traumatic incidents and large scale disasters with evidence-based public health/mental health intervention protocols incorporating ethnocultural, gender and developmental specificity so that the majority of survivors are stabilized and/or referred appropriately within the first 72 hours of the incident or disaster occurring.

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Post Traumatic Stress Management Training Post Traumatic Stress Management Training and Psychological First Aidand Psychological First Aid

With Ethnocultural, Gender and Developmental Specificity (cont.)With Ethnocultural, Gender and Developmental Specificity (cont.)

Training objectives: Identify historical perspectives and responses to helping people who have experienced psychological trauma and the resulting traumatic stress including ethnocultural and gender variables Describe Psychological First Aid (PFA) Analyze the PFA’s eight (8) core functions Compare theoretical models describing the subjective experiences of traumatic stress and resiliency in US adults, children, and various ethnocultural and diverse groups Analyze physiological and biological reactions that may occur during a traumatic stress response with focus on ethnocultural variables Design and conduct PFA and PTSM continuum of care protocols sensitive to diversity, gender, and developmental stages, and as applied to TLC-PTSM Incident Command.

About the Presenter: Robert D. Macy, Ph.D. is the Founder and Executive Director of the Boston Center for Trauma Psychology, the Co-Director of a Category III National Center for Child Traumatic Stress Network site in Boston, Founder and Executive Director of The Children’s Trauma Recovery Foundation, also in Boston, and a Research Associate in Psychology in the Department of Psychiatry at Harvard Medical School. Dr. Macy is a pioneer in the field of Traumatic Incident Stress Interventions for children, youth, their families and their communities exposed to traumatic events including large-scale disasters, terrorist events, and political, community and armed conflict violence. He designs, implements and evaluates traumatic stress reduction programs and psychosocial assessment and intervention projects in the United States, Palestine, Israel, Afghanistan, Nepal, Indonesia, Sri Lanka, Sudan, Burundi, Sierra Leone and South Africa.

Training Overview: PTSM is a model developed and tested extensively in the field over the last 10 years by Robert D. Macy, PhD.  This PTSM training series includes the most current components of psychological first aid, psychosocial stabilization and resiliency enhancement.  Attendees are taught the skills used to identify, stabilize and augment the psychosocial needs of children who have been exposed to life threatening events including traumatic loss from accidents, suicide, homicide, illness, and larger impact disasters.

Professional Contact Hours Provided

Please note that participants may not be eligible for continuing education credits if they are not on time and present for the entire session. Participants must sign in and sign out. Participants must submit a completed evaluation form at the end of the program. Partial credits will not be issued to participants arriving late or leaving early.

Certificate Fee for Professional Contact Hours is $20 payable by separate check or money order ONLY after the conference. 

Certified Counselors: University Behavioral HealthCare (UBHC) is an NBCC Approved Continuing Education Provider (ACEPTM) and a co-sponsor of this program. UBHC may award NBCC approved clock hours for events or programs that meet NBCC requirements. The ACEP maintains responsibility for the content of this program. (20 hours). Approval Number 6198.Educators: May receive credit for twenty ( 20) Professional Development Hours. There is no charge for this certificate.Nurses: University Behavioral HealthCare is an approved provider of continuing nursing education by the New Jersey State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. P#204-7/09-12.  (20 contact hours) Psychologists: University Behavioral HealthCare is approved by the American Psychological Association to sponsor continuing education for psychologists. University Behavioral HealthCare maintains responsibility for the program and its content. Instructional Level: Beginning. (20 CE Credits)

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Post Traumatic Stress Management Training Post Traumatic Stress Management Training and Psychological First Aidand Psychological First Aid

With Ethnocultural, Gender and Developmental Specificity (cont.)With Ethnocultural, Gender and Developmental Specificity (cont.)

Professional Contact Hours Provided (cont.)

Screener Recertification: In compliance with UMDNJ-University Behavioral HealthCare-Technical Assistance Center (TAC) policy, 20 full TAC Continuing Education credits will be issued only to Screeners who attend the entire scheduled class. There is no charge for this certificate.Social Workers: University Behavioral HealthCare of the University of Medicine & Dentistry of New Jersey, provider #1173, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org, through the Approved Continuing Education (ACE) program from August 10, 2009 to August 10, 2012. University Behavioral HealthCare of the University of Medicine & Dentistry of New Jersey maintains responsibility for the program. Social workers participating in this course will receive 20 clinical continuing education clock hours. Targeted social work practice level: Intermediate.IMPORTANT NOTE: Social Workers must be prepared to write in their Social Work license/certification/registration number and license jurisdiction on the sign in sheet. Please be sure to bring this information with you to the training.ASWB credits accepted by the New Jersey State Board of Social Workers. For other states go to www.aswb.org to confirm that state acceptance of ASWB credits.

Please contact Sharon Eaton at (732) 235-9282 with any questions or concerns regarding social work continuing education documentation for this training.

Pre-Registration Required

Cost: $325 Includes: Continental Breakfast, Lunch for Day 1 & 2 Only, and Conference Materials Checks, Money Orders, Purchase Orders ONLY Make Checks Payable to UMDNJ - UBHC

Intended Audience: TLC Coalition Members and Coordinators School Counselors - School Resource Officers - Educators School Administrators - School Psychologists - School Nurses Mental Health Clinicians - Division of Family Services Personnel Juvenile Justice Personnel - Law Enforcement Personnel – Clergy - Substance Abuse Counselors - Child Psychiatrists - Pediatricians

Confirmation: ALL confirmations will be sent by e-mail only. Please bring confirmation to the conference. Without the emailed confirmation, you are not registered.

Cancellation Policy: Refund ONLY if cancellation is received by October 23, 2009. Refund processing fee is $20.

Special Needs: For special physical or dietary requirements, contact the TLC at 732-235-2810 to discuss possible provisions.

IMPORTANT NOTE: There is an additional charge of $20 for the professional continuing education certificates for each of the three training programs. This fee is ONLY payable after the completion of each training program. For further information call (732) 235-2810.

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Post Traumatic Stress Management Training Post Traumatic Stress Management Training and Psychological First Aidand Psychological First Aid

With Ethnocultural, Gender and Developmental Specificity (cont.)With Ethnocultural, Gender and Developmental Specificity (cont.)

Dates Training

October 27-29, 2009 3-Day Certificate PTSM Training Program

* March 4, 2010 Advanced PTSM – Protocols for Response to Homicide & Gang Violence

* March 5, 2010 Advanced PTSM – Protocols for Response to Suicide

*Additional registration will be required for each Advanced PTSM training program

WITHOUT AN EMAIL CONFIRMATION ~ YOU ARE NOT REGISTERED

SEATING IS LIMITED REGISTER TODAY

For further information, please call 732-235-2810.

Please mail the registration form with the $325 fee or purchase order to: UMDNJ - UBHC - BRTI Traumatic Loss Coalitions for Youth151 Centennial Avenue, Piscataway, NJ 08854

Note: REGISTRATION DEADLINE: Thursday October 22, 2009Checks, Money Orders, or Purchase Orders ONLY

NO CASH OR CREDIT / DEBIT CARDSMake Checks Payable to UMDNJ – UBHC

TO REGISTER ONLINE GO TO

http://ubhc.umdnj.edu/brti/TLC.htm

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CLINICAL TRAININGS

American Red Cross

Standard First Aid and CPR CourseFor the Lay Person (Not RN’s or MD’s)

Date: Wednesday, September 23, 2009 Time: 8:00 AM – 4:30 PMLocation: Training Room B & G 151 Centennial Avenue Piscataway, NJ 08854Fee: $65 UBHC Staff (Free if this course is required for your UBHC job)

$100 Others Limited to 20 peopleNext Date Offered: Tuesday, March 16, 2010

Course ObjectivesParticipants will learn the following objectives by the end of the course:1. How to respond to an Emergency/The Emergency Plan

1) Introduction2) Deciding to Act and Taking Action3) Checking an unconscious victim4) Checking a conscious victim

2. Adult CPR (adult refers to victims age 9 and up) 1) Learn how to recognize the signals of breathing emergencies

2) Learn to care for a choking adult3) Learn to care for an adult who stops breathing4) Learn how to reduce the risk of a heart attack5) Learn the signals of a heart attack6) Learn how to provide care for a heart attack7) Learn to give CPR to an adult

3. First Aid: Recognizing and caring for an injury or sudden illness1) Head, neck, and spine injuries 7) Bites and Stings2) Broken bones 8) Poisoning3) Burns 9) Heat and Cold-Related Illness4) Wounds 10) Seizures5) Fainting 11) Diabetic Emergency

6) Shock

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CLINICAL TRAININGS

UMDNJ - University Behavioral HealthCareTraining and Consultation Resources

Presents

Youth Gang Involvement In New Jersey

FEATURED SPEAKER

Jack Farrell, LCSW UMDNJ-Violence Institute of New Jersey

Mr. Farrell speaks around the state on gangs and gang activity in New Jersey. Mr. Farrell has extensive experience working with communities and local agencies in regard to gang related activities. During his thirty year career in state leadership, his roles included Acting Assistant Commissioner and Deputy Director for the Division of Addiction Services. Mr. Farrell has also provided case management services for the Newark Safer Cities Initiative. He has been recognized at community, state and federal levels for his commitment to community service.

The goal of this training is to provide information on current trends in youth gangs in New Jersey and effective strategies for community response.

Date: Wednesday September 30, 2009Time: 9:30 am – 4:30 pm  Location: Training Room “B”

UBHC151 Centennial Ave

Piscataway, NJ 08854Fee: UBHC with ID: $30

Other Professionals: $50 Fee includes handouts, continental breakfast and lunch.

Program Objectives: At the end of this training you will be able to:1. Describe risk factors for gang involvement.2. Describe common gangs and gang identifiers in New Jersey. 3. Identify the community’s responsibility to protect children and support families as it relates to gang involvement and gang violence. 4. Describe the impact of culture and violence on gang involvement.5. Describe the roles and responsibilities of various community agencies and the importance of inter-agency collaboration as they relate to addressing gang involvement and gang violence.6. Identify strategies to engage extended family members and community providers to protect children from gang involvement and gang violence in their home communities.

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CLINICAL TRAININGS

Youth Gang Involvement In New Jersey (cont.)

Agenda

9:30 am Introduction9:45 am What is a gang?

Myths about gang membersWhy youth join gangs3 R’s of gang culture: Reputation, Respect, Retaliation

10:00 am NJ Attorney General DVD on gangs and current gang activity in NJMethods of gang identification: tattoos, clothing, area codes, etc.

10:45 am BREAK11:00 am Gangs in NJ (Latin Kings, Bloods, Crips, M-13, Netas, Vatos Locos, Outlaw

Motorcycle Gangs, White Supremacist/Hate Groups)12:30 pm LUNCH1:30 pm Overcoming Community Denial

Contagion and Correlates of Violent BehaviorAddressing Gang Graffiti: Read, Report, Record, Remove

2:00 pm History of Gangs in AmericaGang presence in military and professional sports

2:45 pm BREAK3:00 pm Community based responses to youth risk factors Community Gang Activity Assessment Tool: Warning signs of gang activity School-based interventions Roles of community-based and faith-based organizations3:45 pm Protective factors and role of the family in supporting positive outcomes for youth

What parents can do4:20 pm Evaluations

Professional Contact Hours

Important Note: Certificate Fee for Professional Contact Hours is $20 payable by separate check or money order only after the training has been completed. Certificate will be mailed within two weeks of the training to participants who have met all requirements.

Professional contact hour eligibility requirements:Participants must sign in and sign out and place their full address on the sign in sheet.Social Workers will be required to place their license/certification/registration number and license jurisdiction on the sign in sheet.Participants must complete and submit the program evaluation. Participants may not be eligible for continuing education credits if they are not on time and present for the entire session.Partial credits will not be issued to participants arriving late or leaving early.

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CLINICAL TRAININGS

Youth Gang Involvement In New Jersey (cont.)

Professional Contact Hours (cont.)

Certified Counselors: University Behavioral HealthCare (UBHC) is an NBCC Approved Continuing Education Provider (ACEP™) and a co-sponsor of this event/program. UBHC may award NBCC approved clock hours for events of programs that meet NBCC requirements. The ACEP maintains responsibility for the content of this event. (5 Clock Hours) Approval Number 6198.Nurses: University Behavioral HealthCare is an approved provider of continuing nursing education by New Jersey State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.  P#204-7/09-12.  (5.25 contact hours) Social Worker: University Behavioral HealthCare of the University of Medicine & Dentistry of New Jersey, provider #1173, is approved as a provider (August 10, 2009 through August 10, 2012) for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org, through the Approved Continuing Education (ACE) program. University Behavioral HealthCare of the University of Medicine & Dentistry of New Jersey maintains responsibility for the program. Social workers participating in this course will receive 5 competence continuing education clock hours. Targeted social work practice level: Beginning. Please check with your state board regarding jurisdictional approval for this program.NOTE: Social Workers must provide their Social Work license number and license jurisdiction on the sign in sheet and request for certificate. Please be sure to bring this information with you to the training.Psychologists: University Behavioral HealthCare is approved by the American Psychological Association to sponsor continuing education for psychologists. University Behavioral HealthCare maintains responsibility for the program and its content. Instructional level: Introductory. (5 CE Credits).

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CLINICAL TRAININGS

Ethics and Law in Social Work ServicesFeaturing

Christine M. Heer, Esq., MSW, LCSW, DVS

Every social worker needs to take 5 continuing education hours in ethics each re licensing period. This ethics program will meet social work licensure requirements.

Date: Thursday, October 8, 2009Time: 9:30 am to 3:30 pmPlace: UMDNJ – University Behavioral HealthCare Conference Room B & G 151 Centennial Avenue Piscataway, New Jersey 08854 Free parkingFee: UBHC Staff with ID’s: $30 Other Professionals: $100 Fee Includes: Breakfast and Lunch, Handouts

Program OverviewThis workshop will examine the ethical and professional responsibilities that social workers have to their clients, to their colleagues and to the profession. Topics will include confidentiality and evidentiary privilege, duties and standards of care, and the role of the NASW Code of Ethics and licensure regulations. Participants should be prepared to discuss hypothetical situations and strategize responses that include both legal and social work ethical requirements.

Program Objectives: At the end of this training you will be able to:1. Distinguish between law and ethics2. Examine the risks of unethical practice3. Review the NJ legal system4. Discuss common areas of ethical violations5. Examine duties of the social worker and how the duties related to practice

Agenda

9:30 AM - 10:00 AM Distinctions Between Ethics and Law10:00 AM – 10:15 AM The Risks of Unethical Practice10:15 AM – 10:30 AM NJ Legal System10:30 AM – 10:45 AM Ethics Violations Professional Responsibilities10:45 AM – 11:00 AM Break11:00 AM – 12:00 PM Confidentiality, Wigmore, and Privilege12:00 PM – 1:00 PM Lunch1:00 PM – 2:00 PM Privilege, Duty to Protect, Duty to Warn and Duty to Treat2:00 PM – 2:15 PM Break2:15 PM – 2:45 PM Duty to the Profession2:45 PM – 3:20 PM Relationship with Clients

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3:20 PM – 3:30 PM EvaluationContinued Next Page

CLINICAL TRAININGS

Ethics and Law in Social Work Services (cont.)

Professional Contact HoursImportant Note: Certificate Fee for Professional Contact Hours is $20 payable by separate check or money order only after the training has been completed. Certificate will be mailed within two weeks of the training to participants who have met all requirements.

Professional contact hour eligibility requirements:Participants must sign in and sign out and place their full address on the sign in sheet.Social Workers will be required to place their license/certification/registration number and license jurisdiction on the sign in sheet.Participants must complete and submit the program evaluation. Participants may not be eligible for continuing education credits if they are not on time and present for the entire session.Partial credits will not be issued to participants arriving late or leaving early.

Social Worker: University Behavioral HealthCare of the University of Medicine & Dentistry of New Jersey, provider #1173, is approved as a provider (August 10, 2009 through August 10, 2012) for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org, through the Approved Continuing Education (ACE) program. University Behavioral HealthCare of the University of Medicine & Dentistry of New Jersey maintains responsibility for the program. Social workers participating in this course will receive 5 ethics competence continuing education clock hours. Targeted social work practice level: Intermediate. Please check with your state board regarding jurisdictional approval for this program.NOTE: Social Workers must provide their Social Work license number and license jurisdiction on the sign in sheet and request for certificate. Please be sure to bring this information with you to the training.

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Registration Details

Course Confirmation ProcedureTo ensure accurate course participant registration, TCR will send email confirmation to all course participants 3 working days prior to a TCR course. If you do not receive this confirmation email, in which you believe you are pre- registered for a course, please call us at (732) 235-9282 so that you can enroll in the course.

Cancellation PolicyIf you cannot attend the program, please call (732) 235-9282 so that we can fill your seat with individuals on the program waiting list.

Refund PolicyA full refund can be received up to 48 hours of the first date of the training, less a 15% processing fee. Refunds cannot be given for a cancellation less than 48 hours prior to the first day of a training or a “no show”.

Inclement WeatherYou may call (877) 863-4968 to obtain an announcement if UMDNJ – University Behavioral HealthCare is closed due to inclement weather. If UMDNJ-University Behavioral HealthCare is closed, the program you have registered for will be canceled and rescheduled. A full refund will be made available upon a written request received within two weeks of the canceled program.

Special NeedsIf you have special physical or dietary requirements and wish to discuss possible provisions, please contact Training and Consultation Resources at (732) 235-9282.

Additional InformationAll Centennial Avenue attendees must enter via the main door and register with the receptionist.

University Behavioral HealthCare employees: Be sure to wear your UMDNJ ID badge.

Sweaters and jackets are recommended to accommodate for room temperature variations.

For further information and/or grievances contact Training and Consultation Resources at (732) 235-9282.

UMDNJ reserves the right to modify the program content, program faculty, and program activities, and reserves the right to cancel the program if needed.

Registration Form Next Page

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PRINT THIS FORM COMPLETE AND FAX TO 732-235-2850

Or if payment is required - Mail with payment to University Behavioral HealthCare

Training and Consultation Resources151 Centennial AvenuePiscataway, NJ 08854

You may duplicate and use one form for each registration.

REGISTRATION FORM Must Be Completed In Full To Be Registered

Course Title ____________________________________________________

Date/Time ____________________________________________________

Name ____________________________________________________

Organization ___________________________________________________

ProfessionalTitle: ___________________________________________________

Address: ___________________________________________________

___________________________________________________

Phone ___________________________________________________

Email ___________________________________________________

Registration Fee Must Accompany Registration: $_____________________Checks or money orders only (payable to UMDNJ-UBHC)

Contact Hour Fee: Payment is to be mailed to the above address after attending the program. Contact hour fee is only accepted with the contact hour request form which is to be mailed in, with payment, after the program.

UBHC STAFF ONLY: (Please Complete All Information)

Supervisor’s Signature _____________________________________________

Supervisor’s Name (Print) _____________________________________________________

Please SELECT ONE of the following campuses AND name of your unit/program.____ New Brunswick____ Newark Unit/Program Name: ___________________________

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____ Piscataway Work Address: ____________________________________ Stratford

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