Name of organization:

Contact person:

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Name of event:

Date of event:

Is the date flexible? Yes  No

Time of event: Select one morning afternoon evening weekend Other (specify):

What type of event (conference, training, inservice, other?)

Select one conference training inservice Other (specify):

Location where event will be held:

How far is the location from Minneapolis/St. Paul? miles

Topic requested for presentation: Select one Bridging Education and Mental Health Early Language and Literacy Development IGDIs and Get It! Got It! Go! Introduction to Infant Mental Health Positive Behavior Support Reflective Supervision Seeing is Believing (only) STEEP (only) STEEP/SIB Combined Training Supporting Stressed Young Children

How many participants will there be? Select one 1-10 10-25 25-50 50-75 75-100 100+

Who will participate?

What are the participants' level of knowledge about the topic? Select one Beginner Intermediate Advanced Mixed

What are the three to five major areas of concern regarding the topic?

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2.

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5.

Yes, I have reviewed the training terms and fees.

Additional Comments:

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