**Registration Form**

US Department of Education/Office of Safe and Drug-Free Schools

Grants to Reduce Alcohol Abuse

**Central Regional Technical Assistance Grantees Meeting**

**May 4-5, 2006**

Adam's Mark Hotels and Resorts

2544 Executive Drive, Indianapolis, IN 46241

*This form may be completed within MS Word by using the tab key to move
between fields. Use the left mouse button to check boxes.*

**Participant Name**: **First**:      **Last**:     

**Title/Position**:     

**Employer/School District**:     

**Mailing Address**:      **City**:      **State**:     

**Work phone with area code**:      **Fax number with area code**:     

**Email address**:     

**Emergency contact**:      **Emergency contact phone number with area
code**:     

**Ethnicity** - mark one **Race** - mark one or more

Hispanic or Latino American Indian or Alaska Native Native Hawaiian or

*Not* Hispanic or Latino Asian other Pacific Islander

Black or African American White

**Primary Affiliation/Representation**

Which one of the following best describes your primary affiliation?

Single State Agency -- ATOD Community Coalition Public Health Agency

Business Cooperative Extension Mental Health Provider

Prevention Program/Org. Education - K-12 Substance Abuse Treatment

Military Education -- Higher Education Welfare Agency

Media Faith Community Other Social Services

Criminal Justice Health Care Provider Other Govt. Agency/Elected
Official

Other:     

**If applicable, please provide special dietary requirements:**

Vegetarian:      Vegan Vegetarian:     

Kosher:      Other:     

**[DEADLINE FOR REGISTRATION: APRIL 13, 2006]{.underline}**

**Please return your registration by email, mail or fax to:**

Jan Caron

CSAP's Central CAPT\
2720 Hwy 10 NE

Mounds View, MN 55112

FAX: 763-427-7841

jcaron@miph.org

**[NOTE:]{.underline} [This form registers you for the Regional
Technical Assistance Grantees meeting only]{.underline}. You will
receive a confirmation by fax, mail, or email. Please make your hotel
reservations using the information provided on the separate hotel
information sheet.**

**ATTACHMENT:** Central CAPT DOE Grants to Reduce Alcohol Abuse Grantee
Model Programs by city/state.

**QUESTIONS?** Contact either Jeanne Carls at <jcarls@miph.org> or Tou
Lee at <tlee@miph.org> or either one at

1-800-782-1878

**Central CAPT Department of Education**

**Grants to Reduce Alcohol Abuse Grantee Model Programs**

+----+-----------------------+-----------------------------------------+
|    | **Grantee**           | **Model Program(s)**                    |
|    |                       |                                         |
|    | **City/State**        |                                         |
+----+-----------------------+-----------------------------------------+
| *  | Bucyrus, OH           | 1\) Project Success                     |
| *1 |                       |                                         |
| ** |                       | 2\) Creating Lasting Family Connections |
|    |                       |                                         |
|    |                       | 3\) CMCA                                |
+----+-----------------------+-----------------------------------------+
| *  | Athens, OH            | 1\) Project Success                     |
| *2 |                       |                                         |
| ** |                       | 2\) Creating Lasting Family Connections |
+----+-----------------------+-----------------------------------------+
| *  | Columbus, OH          | 1\) Keepin' It Real                     |
| *3 |                       |                                         |
| ** |                       |                                         |
+----+-----------------------+-----------------------------------------+
| *  | Almond, WI            | 1\) Positive Action                     |
| *4 |                       |                                         |
| ** |                       |                                         |
+----+-----------------------+-----------------------------------------+
| *  | Columbus, WI          | 1\) Class Action                        |
| *5 |                       |                                         |
| ** |                       | 2\) CMCA                                |
|    |                       |                                         |
|    |                       | 3\) Parenting Wisely                    |
+----+-----------------------+-----------------------------------------+
| *  | Rockford, IL          | 1\) Class Action                        |
| *6 |                       |                                         |
| ** |                       |                                         |
+----+-----------------------+-----------------------------------------+
| *  | Aurora, IL            | 1\) LifeSkills                          |
| *7 |                       |                                         |
| ** |                       | 2\) Strengthening Families Program      |
+----+-----------------------+-----------------------------------------+
| *  | Chicago, IL           | 1\) Project Success                     |
| *8 |                       |                                         |
| ** |                       |                                         |
+----+-----------------------+-----------------------------------------+
| *  | Detroit, MI           | 1\) Project Success                     |
| *9 |                       |                                         |
| ** |                       |                                         |
+----+-----------------------+-----------------------------------------+
| ** | Washington, IA        | 1\) Reconnecting Youth                  |
| 10 |                       |                                         |
| ** |                       | 2\) CMCA                                |
+----+-----------------------+-----------------------------------------+
| ** | Anamosa, IA           | 1\) Leadership & Resiliency             |
| 11 |                       |                                         |
| ** |                       | 2\) Project Towards No Drug Abuse       |
|    |                       |                                         |
|    |                       | 3\) LifeSkills                          |
|    |                       |                                         |
|    |                       | 4\) Project Alert                       |
|    |                       |                                         |
|    |                       | 5\) CMCA                                |
+----+-----------------------+-----------------------------------------+
| ** | Evansville, IN        | 1\) Project Success                     |
| 12 |                       |                                         |
| ** |                       | 2\) Reconnecting Youth                  |
+----+-----------------------+-----------------------------------------+
| ** | Logansport, IN        | 1\) LifeSkills                          |
| 13 |                       |                                         |
| ** |                       | 2\) Keepin' It Real                     |
|    |                       |                                         |
|    |                       | 3\) Leadership & Resiliency             |
+----+-----------------------+-----------------------------------------+
| ** | Brimley, MI           | 1\) Too Good for Drugs                  |
| 14 |                       |                                         |
| ** |                       | 2\) Reconnecting Youth                  |
+----+-----------------------+-----------------------------------------+
| ** | Rudyard, MI           | 1\) Reconnecting Youth                  |
| 15 |                       |                                         |
| ** |                       | 2\) Creating Lasting Family Connections |
+----+-----------------------+-----------------------------------------+
| ** | Scottville, MI        | 1\) Leadership & Resiliency             |
| 16 |                       |                                         |
| ** |                       |                                         |
+----+-----------------------+-----------------------------------------+
| ** | Warren, MN            | 1\) Too Good for Drugs                  |
| 17 |                       |                                         |
| ** |                       |                                         |
+----+-----------------------+-----------------------------------------+
| ** | Belcourt, ND          | 1\) Reconnecting Youth                  |
| 18 |                       |                                         |
| ** |                       |                                         |
+----+-----------------------+-----------------------------------------+
| ** | Grand Forks, ND       | 1\) Project Northland                   |
| 19 |                       |                                         |
| ** |                       | 2\) Class Action                        |
+----+-----------------------+-----------------------------------------+
| ** | Kyle, SD              | 1\) Reconnecting Youth                  |
| 20 |                       |                                         |
| ** |                       |                                         |
+----+-----------------------+-----------------------------------------+