Participant Registration
Due: January 27, 2003

 

Invitation (sent to Program Managers and EETAP Partners 1/13/03)

Participant Input Survey - If you register after January 27th, please return to this page and click on this link to help make the clinic �participant driven�.

Please complete this registration and submit by January 27, 2003.

State select a state Arizona California Illinois Missouri Ohio Oklahoma Utah Washington Other     or    Community select a community Chapparal, NM Oklahoma City, OK Orange County, CA Other

Choose one:
Team Leader  Team Member  EETAP Partner  Resource Person

Name

Organization
Title

Address
City   State    Zip

Phone

Fax      Email

   

Please feel free to contact Abby Ruskey at 360-754-4518 or amruskey@earthlink.net if you have any questions related to the clinic or registration.

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