Individual Registration: Webcast - May 25, 2005

Please complete the following form.

Required fields are indicated with a red asterisk *

 

* Email address

* Street Address 1

* First Name Street Address 2
* Last Name * City
 Title * State
 Department * Zip
* Organization  Phone
    Fax

*  Are you affiliated with any of the follwing grants? (select all that apply)

DFC grant
Don't Know

SIG grant
Don't Know

USED Underage Drinking grant
Don't Know

USED SDFS grant
Don't Know

DOJ WEED and SEED grant
Don't Know

Ecstasy and Other Club Drugs grant
Don't Know

Earmark grant
Don't Know

Metamphetamine/Inhalant grant
Don't Know

How do you plan on accessing this event?

Webcast (from your computer)
Satellite Broadcast (downlinked site)

Which one of the following best describes the primary focus of your organization?
If you selected other, please specify
Which one of the following best describes your ethnicity?
If you selected other, please specify
Please submit questions here that you would like the panelist to address:

       
 
Copyright 2002 Education Development Center, Inc.
All rights reserved. 1-888-332-2278