The charge for this training is as follows: October 16 & 17, 2008 NJ Schools Participants (Space Limited) No charge Non-School NJ Participants $200 Out of State Participants $400
TRAINING CONFIRMATION Upon submitting your registration, a separate confirmation will be sent to you.  If you do not receive this within 3 days, please contact Nancy Edwards at 732-235-8218 at the Tobacco Dependence Program.
Please choose training dates October 16 & 17 2008
Mr. Mrs. Miss Ms. Dr. Rev.
First Name
Last Name
Degrees/Certifications
Years counseling experience
Title
Organization
Address
Address (cont.)
City
State
Zip Code
County
Work Area Code+ Phone
Work Area Code + FAX
Email REQUIRED
How did you hear about this training?
Home Information
Home Address
Home City
Home State
Home Zip Code
Home Area Code+ Phone
Cell Phone
Emergency Contact
Relationship
Area Code + Phone
Cell Phone
Additional Information
Do you have experience working with teens? Yes No
If Yes, how many years?
Do you have experience in addiction counseling? Yes No
If Yes, how many years?
Do you work in a school? Yes No
If yes, what grades does your school service?
Have you ever used another Youth Cessation Program? Yes No
If Yes, indicate name of program/curriculum

Remember to send your payment to:
UMDNJ-Tobacco Dependence Program
317 George Street, Suite 210, New Brunswick, NJ 08901