Mental Illness Workshop Registration

Please fill out the information below to register for one of the Mental Illness workshops.

After filling out the registration information, you will be directed to our Web Cart where you can complete the registration by selecting and making the $10 payment for the workshop that you will be attending.

Workshop: *

Washington, DC July 11, 2009

Chicago, IL July 21, 2009

Portland, OR July 24, 2009

Title:

Your title, i.e. Mr. or Mrs. or Rev.

First Name: *

Last Name: *

Suffix:

The initials that follow your name, i.e. Ph.D. or OFM

Organization:

Position:

What is your work title or position. (Optional)

Street 1: *

Street 2:

City: *

State: *

Postal Code: *

Primary Phone: *

The primary phone where you can be reached if necessary.

Primary Phone Type: *

Home

Work

Cell

Please enter the primary phone where you would like to be contacted if necessary

Alternate Phone:

A secondary phone number where you can be reached if necessary.

Alternate Phone Type:

Home

Work

Cell

A secondary phone number where you can be contacted

Fax:

Email: *

Thanks to the Knights of Columbus for their generous support of NCPD.

National Catholic Partnership on Disability

Mental Illness Workshop Registration