Health/Senior Training (Sept. 13-14, 2010) Tampa, FL

Answer questions as they relate to you. For most answers, check the boxes most applicable to you or fill in the blanks. ON-LINE REGISTRATION DEADLINE - SEPTEMBER 3, 2010. If you require hotel accommodations, please note the deadline for making hotel reservations below.

The Health/Senior Training will be held at the Embassy Suites Hotel -USF/Busch Gardens, 3705 Spectrum Blvd, Tampa FL, Monday-Tuesday, September 13-14, 2010. The training will begin at 10:00 on Monday and conclude by 3:00 p.m. on Tuesday. You will be responsible for making your own hotel reservations (see Hotel Accommodations). Hotel reservations must be received by AUGUST 13, 2010.

If you have any questions please contact Kathy Grunewald or Sharon Ferguson at the email addresses or telephone numbers listed below.

Thank you.

Kathy Grunewald
Statewide Director of Training
Florida Legal Services, Inc.
kathy@floridalegal.org
(850) 385-7900

Sharon Ferguson
Training Coordinator
Florida Legal Services, Inc.
sharon@floridalegal.org
(904) 768-8561

Please provide the following (*required)

First Name*

Last Name*

Email*

Program Information

1.	Legal services/Legal Aid program name (Please provide program's full name, DO NOT use acronyms)

2.	Program Mailing Address

3.	Phone Number

4.	Fax Number

5.	Please provide the billing address for your program. If the address is the same as listed in Question #2 (Program Mailing Address), please leave blank.

General Information

6.	I am registering as a:

	Faculty Member (Skip to Q. 12)
	Training Participant

7.	I receive Title IIIB funding

	Yes
	No

8.	I practice primarily in Title IIIB areas

	Yes
	No

Your role

	Advocacy - Attorney: Staff Attorney (Senior - 3 or more years experience)
	Advocacy - Attorney: Staff Attorney (Junior - 0 to 3 years experience)
	Advocacy - Attorney: Director
	Advocacy - Attorney: Supervising Attorney
	Advocacy - Paralegal (Senior - 3 or more years experience)
	Advocacy - Paralegal (Junior - 0 to 3 years experience)
	Administration - Executive Director
	Administration - Deputy Director
	Administration - Managing Attorney
	Other:

10.	List your YEARS in practice:

11.	List your YEARS in legal aid (including with your CURRENT organization):

Dietary Needs

PLEASE NOTE: We cannot guarantee true vegetarian/vegan meals. Nor can we provide or guarantee food is free of any specific allergen (e.g. soy, diary, wheat, nuts, etc.). Any participant likely to suffer a severe anaphylactic reaction to an allergen or on a restrictive diet may want to consider bringing their own food items.

12.	My dietary needs are

	None
	Vegetarian (No animal products, only vegetables, fruits, and sometimes eggs or dairy products)
	Vegan (Strict - no animal food or dairy products)

Hotel Accommodations

A rooming block has been reserved at the Embassy Suites-USF/Busch Gardens, Tampa, FL. Reservations can be made by emailing Ermy Rosales at ermy.rosales@jqh.com or by calling Ms. Rosales at 813-977-7066 (Reservation Department). To receive the group rate, you must identify yourself as part of the "Health/Senior" training. Room rates are $105.00 per night. Reservations must be made by AUGUST 13, 2010. Reservations made after this date will be accepted on a space available basis.

Cancellations must be made by 4:00 p.m. the day before arrival. Please confirm the cancellation policy when making your reservation.

All hotel rooms will be master billed to Florida Legal Services. FLS will then in turn, invoice your program. A credit card or cash deposit will be needed at check-in to cover incidentals (i.e. telephone calls, internet access, room service, etc.). Please note, should you withdraw from the training, you must remember to cancel your hotel reservations (if applicable). Should a failure to cancel your reservation result in a "No Show" charge to the FLS master account, we will bill your program.

Thank You

Please be sure you have provided a viable work email address, all future communications will be through emails.

You will receive a confirmation email once your registration is completed. Occasionally due to email restrictions this confirmation may not be accepted by your email server. DO NOT submit another registration. Contact our Training Coordinator, Sharon Ferguson at sharon@floridalegal.org to confirm whether your registration was received.

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