+----------------+---------------------------+-------+---+------------+
| **Registration |                           |       |   |            |
| Form**         |                           |       |   |            |
+----------------+---------------------------+-------+---+------------+
| > **Title of   | **VIST/BROS Training      | **Pr  |   | **August   |
| > Program:**   | Conference**              | ogram |   | 15-17,     |
|                |                           | Date( |   | 2006**     |
|                |                           | s):** |   |            |
+----------------+---------------------------+-------+---+------------+
| **Location of  | **Adams Mark, Buffalo,    |       |   |            |
| Program:**     | NY**                      |       |   |            |
+----------------+---------------------------+-------+---+------------+
| **EES Contact  | **Mary J. Carroll**       | **Emp |   |            |
| Person:**      |                           | loyee |   |            |
|                |                           | Educ  |   |            |
|                |                           | ation |   |            |
|                |                           | Res   |   |            |
|                |                           | ource |   |            |
|                |                           | Cen   |   |            |
|                |                           | ter** |   |            |
+----------------+---------------------------+-------+---+------------+
| > **Contact    | [**Ma                     | **1   |   |            |
| > Person       | ry.carroll5@va.gov**](mai | Jeff  |   |            |
| > Email:**     | lto:Mary.carroll5@va.gov) | erson |   |            |
|                |                           | Bar   |   |            |
|                |                           | racks |   |            |
|                |                           | Drive |   |            |
|                |                           | (14B/ |   |            |
|                |                           | JB)** |   |            |
+----------------+---------------------------+-------+---+------------+
| > **Phone:**   | **314-894-6648 x 64138**  | **St  |   |            |
|                |                           | Louis |   |            |
|                |                           | MO    |   |            |
|                |                           | 63    |   |            |
|                |                           | 125** |   |            |
+----------------+---------------------------+-------+---+------------+
| > **Fax:**     | **314-894-6506**          | >     | * |            |
|                |                           | **DUE | * |            |
|                |                           | > DA  | J |            |
|                |                           | TE:** | u |            |
|                |                           |       | l |            |
|                |                           |       | y |            |
|                |                           |       | 7 |            |
|                |                           |       | , |            |
|                |                           |       | 2 |            |
|                |                           |       | 0 |            |
|                |                           |       | 0 |            |
|                |                           |       | 6 |            |
|                |                           |       | * |            |
|                |                           |       | * |            |
+----------------+---------------------------+-------+---+------------+

+---+-------------------------+-------+---+------------------------------+
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+---+-------------------------+-------+---+------------------------------+
|   |                         |       |   |                              |
+---+-------------------------+-------+---+------------------------------+
|   | > **I will attend 100%  |       |   | > **I will attend only a     |
|   | > of the program**      |       |   | > portion of the             |
|   |                         |       |   | > conference**               |
+---+-------------------------+-------+---+------------------------------+

  ------------------ ------------------------ ------------ ---------- ---------- -- ---------- -- ------------ --- --
  **A. PERSONAL                                                                                                    
  INFORMATION**                                                                                                    

  **Name:**                                                **Sex:**                 **Male**      **Female**       

  **Degree(s):**                                                      **Last 4                                     
                                                                      of Social                                    
                                                                      Security                                     
                                                                      #:**                                         

  **Position /                                                                                                     
  Title:**                                                                                                         

  **VA Facility or                                                                                                 
  Organization:**                                                                                                  

  **Mailing                                                                                                        
  Address:**                                                                                                       

  **City / State:**                                                                                                

  **Phone:**                                  **Fax:**                                                             

  **Cell Phone:**                             **Email:**                                                           
  ------------------ ------------------------ ------------ ---------- ---------- -- ---------- -- ------------ --- --

  ---------------- -- ------------------------- ------- --------- -- ------------- -- --------- -- -------- -- ------------ -- ---------------
  **Type of           **Student/Participant**                        **Faculty /                               **Planning      
  Participant:**                                                     Presenter**                               Committee       
                                                                                                               Member**        

                                                                                                                               

  **Employer          **VHA**                   **x**   **VBA**                       **NCA**      **Non-                      **Other
  Category:**                                                                                      VA**                        Federal**
  ---------------- -- ------------------------- ------- --------- -- ------------- -- --------- -- -------- -- ------------ -- ---------------

+---+--------------------+---+---------------------------------+---------+
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+---+--------------------+---+---------------------------------+---------+
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| l |                    |   |                                 |         |
| i |                    |   |                                 |         |
| s |                    |   |                                 |         |
| t |                    |   |                                 |         |
| e |                    |   |                                 |         |
| d |                    |   |                                 |         |
| > |                    |   |                                 |         |
|   |                    |   |                                 |         |
| u |                    |   |                                 |         |
| n |                    |   |                                 |         |
| d |                    |   |                                 |         |
| e |                    |   |                                 |         |
| r |                    |   |                                 |         |
| > |                    |   |                                 |         |
|   |                    |   |                                 |         |
| A |                    |   |                                 |         |
| c |                    |   |                                 |         |
| c |                    |   |                                 |         |
| r |                    |   |                                 |         |
| e |                    |   |                                 |         |
| d |                    |   |                                 |         |
| i |                    |   |                                 |         |
| t |                    |   |                                 |         |
| e |                    |   |                                 |         |
| d |                    |   |                                 |         |
| > |                    |   |                                 |         |
|   |                    |   |                                 |         |
| H |                    |   |                                 |         |
| o |                    |   |                                 |         |
| u |                    |   |                                 |         |
| r |                    |   |                                 |         |
| s |                    |   |                                 |         |
| > |                    |   |                                 |         |
|   |                    |   |                                 |         |
| b |                    |   |                                 |         |
| e |                    |   |                                 |         |
| l |                    |   |                                 |         |
| o |                    |   |                                 |         |
| w |                    |   |                                 |         |
+---+--------------------+---+---------------------------------+---------+
|   | > Administrative   |   | > Allied / Associated Health    |         |
+---+--------------------+---+---------------------------------+---------+
| > |                    |   |                                 |         |
|   |                    |   |                                 |         |
| * |                    |   |                                 |         |
| * |                    |   |                                 |         |
| A |                    |   |                                 |         |
| C |                    |   |                                 |         |
| C |                    |   |                                 |         |
| R |                    |   |                                 |         |
| E |                    |   |                                 |         |
| D |                    |   |                                 |         |
| I |                    |   |                                 |         |
| T |                    |   |                                 |         |
| E |                    |   |                                 |         |
| D |                    |   |                                 |         |
| > |                    |   |                                 |         |
|   |                    |   |                                 |         |
| H |                    |   |                                 |         |
| O |                    |   |                                 |         |
| U |                    |   |                                 |         |
| R |                    |   |                                 |         |
| S |                    |   |                                 |         |
| * |                    |   |                                 |         |
| * |                    |   |                                 |         |
+---+--------------------+---+---------------------------------+---------+
|   | > Architect (AIA)  |   | > Nurse (ANCC)                  |         |
+---+--------------------+---+---------------------------------+---------+
|   | >                  |   | > Nurse (California - CA BRN)   |         |
|   | Audiologist/Speech |   |                                 |         |
|   | > Pathologist      |   |                                 |         |
|   | > (ASHA)           |   |                                 |         |
+---+--------------------+---+---------------------------------+---------+
|   | > Counselor -      |   | > Pharmacist (ACPE)             |         |
|   | > Certified (NBCC) |   |                                 |         |
+---+--------------------+---+---------------------------------+---------+
|   | > Dentist (ADA)    |   | > Physician, PA-C, Advanced     |         |
|   |                    |   | > Practice Nurse (ACCME)        |         |
+---+--------------------+---+---------------------------------+---------+
|   | > Dietician (CDR)  |   | > Psychologist (APA)            |         |
+---+--------------------+---+---------------------------------+---------+
|   | > Healthcare       |   | > Social Worker (ASWB, FLSW,    |         |
|   | > Executive (ACHE) |   | > CASW) **License \#            |         |
|   |                    |   | > Required:**                   |         |
+---+--------------------+---+---------------------------------+---------+

  --------------- ------------------------------ --------- ----------------------------
  **C. EMERGENCY                                           
  INFORMATION**                                            
  While at                                                 
  program, who                                             
  should be                                                
  called in the                                            
  event of an                                              
  emergency:                                               

  **Name:**                                      **Phone   
                                                 #:**      
  --------------- ------------------------------ --------- ----------------------------

  -----------------------------------------------------------------------
  **D. SPECIAL ARRANGEMENTS** Please describe below any requirements due
  to physical limitation(s) or dietary requirements:

  -----------------------------------------------------------------------