Registration

The deadline for registration is February 15, 2012. There is NO REGISTRATION FEE to attend the 2012 JMATE conference.

Please complete the following form in its entirety.

(* Denotes Required Field)

Registration Information:

Salutation:

First Name:

Middle Initial:

Last Name:

Suffix:

Degree:

Organization Name:

Address:

Room/Suite/Floor:

City:

US State/Territory:

Non-US State/Province:

Country:

Postal Code:

* -

Daytime Phone:

* Ext.

Alternate Phone:

Ext.

Fax Number:

Email Address:

Confirm Email Address:

Emergency Contact Information:

Contact Name:

Daytime Phone:

Evening Phone:

Cell Phone:

Role (scroll down to select all that apply)

Clinician/Therapist/Counselor
Community Member (family, advocate)
Consultant/Contractor (Chestnut, JBS)
Educator (faculty; administrator; teacher; counselor)
Evaluator/Research Staff
Federal Government Employee (GPO; administrator)
Juvenile Justice Personnel (judge, probation/parole officer, JDAI)
Medical Professional (physician; nurse)
Other Funding Official (private foundation)
Other Staff Associated with Federal Grant (CEO/CFO; enrollment coordinator; case manager; family liaison)
Principal Investigator/Project Director
Project Coordinator/Program Manager
Single State Authority
State Behavioral Health Representative
Youth/Young Adult (16-27yrs)
Other

Funding: (scroll down to select all that apply)

SAMHSA/CSAT
SAMHSA/CSAP
SAMHSA/CMHS
NIAAA
NIDA
Office of National Drug Control Policy (ONDCP)
OJJDP
RWJF
Department of Labor (DOL)
Department of Education (DoE)
Health Resources and Services Administration (HRSA)
Other

Special Needs:

CEU Interest Level

Do you want any of the following kinds of continuing education credits? (scroll down to select all that apply):

American Psychological Association (APA)

National Board for Certified Counselors (NBCC)

Association of State Social Work Boards (ASWB)

National Association of Social Workers (NASW)

The Association for Addiction Professionals (NAADAC)

Continuing Medical Education (CME)

Continuing Nurse Education (CNE)

Certified Health Education Specialists (CHES)

Meeting materials for JMATE will include a printed roster of names and contact information for registered attendees. The printed roster will be distributed to JMATE attendees and will be posted on the website. Contact information includes each registrant's name, affiliation, mailing address, email address, telephone/fax number. Please let us know if you provide full (all contact information listed) or partial (only name, affiliation, mailing address listed) approval or if you disapprove listing any contact information.

* Allow use of registration information.

Please note: A confirmation email will be sent to you shortly after you submit you registration. If you do not receive a confirmation email, please notify us at jmate-info@jbsinternational.com .